PRACTICAL TREATISE 



ON THE 



DISEASES PECULIAR TO WOMEN: 



ILLUSTRATED BY CASES, 



DERIVED FROM HOSPITAL AND PRIVATE PRACTICE. 



BY 



SAMUEL ASHWELL, M.D., 

MEMBER OF THE ROYAL COLLEGE OF PHYSICIANS, LONDON, AND OBSTETRIC 
PHYSICIAN AND LECTURER TO GUY'S HOSPITAL. 

Second complete ^mectcan ftom t&e last SLonfcorc 3Strttton, 

WITH NOTES, 

BY 

, PAUL B. GODDARD, M.D., M.A.P.S., M.A.N.S., 

LECTURER ON ANATOMY, PHILADELPHIA, ETC. 




PHILADELPHIA: 
LEA AND BLANCHARD. 

1848. 



% 






JBVittVtXi according to the Act of Congress, in the year 1845, by Lea & 
Blanchard, in the Clerk's Office of the District Court of the Eastern 
District of Pennsylvania. 



TO 



BENJAMIN HARBISON, ESQ., 

TREASURER TO GUY'S HOSPITAL, 



THIS WORK 



« 
is 



JUSTLY AND GRATEFULLY INSCRIBED 



BY 



THE AUTHOR. 



PREFACE TO THE ENGLISH EDITION. 

_ It is now more than twenty years since my attention was particularly 
directed to the important branch "of Medical Science which constitutes the 
subject of the following pages. During a great part of this period, Guy's 
Hospital, with its extensive Lying-in-Charity, and my own private and con- 
sultation practice in female diseases, have afforded me opportunities falling 
to the lot of few practitioners. I do not, however, on this account urge any 
exclusive claim to the publication of a work of this kind, nor do I ask for its 
opinions and practice any exclusive or undue deference ; but I trust the truth 
of the principles, and the treatment recommended in the book, will ob tainfor 
it the sanction and confidence of my professional brethren. 

The disposition to publish has been strengthened by an opinion I have long 
entertained, that practitioners, who hold important public appointments, are 
bound, so far as their sources of authentic information can be made subser- 
vient, to improve and increase the common stock of professional knowledge. 
It may, too, be urged in favour of my attempt, that some production of the 
kind is really wanted ; for, while we possess many valuable individual essays 
on female diseases, there are few complete and practical works. 

This treatise was commenced years ago, and but for its difficulty and 
extent, it would long ere now kave been completed. It must be remembered, 
that it is strictly devoted to pathology and treatment, not to anatomical detail 
and physiological research. The latter sciences will therefore be introduced 
for the sole purpose of illustrating disease and the influence of remedies ; 
further they would be irrelevant. 

Numerous cases are narrated, in order that their symptoms may show 
whether the histories of the various diseases are accurately given, and from 
their successful or unfavourable issue, the danger of the malady and the 
worth of the treatment may be demonstrated. These motives will, with prac- 
tical men (and for them I have written), sufficiently apologize for the increased 
size of the volume. Perhaps it may be also urged, that cases add greatly to 
the interest of an elementary work, as they relieve the dulness from which 
a constant repetition of principles, without such portraits, is nearly inseparable. 

The book contains little which is not the result of my own practice and 
observation : and if I have not quoted largely from the works of others, it 
has not arisen from any want of due appreciation of their excellence, nor from 
an unwillingness to acknowledge obligation, but from a conviction that every 
practical book ought mainly to rest on what its author knows and has proved 
for himself to be true and valuable. Where such is the case, a writer natu- 
rally uses a phraseology of his own ; the dress in which he appears before 
the public is seen to belong, not to another but to himself ; and there is con- 
sequently a consistency of arrangement and character throughout the whole. 
Nevertheless, it will be seen on perusal, that I have not omitted to mention 
the names of those from whom I have derived assistance. 

Many formulas of remedies are appended to the various chapters, and this 
has been done, because it harmonized with the practical plan I had prescribed 
to myself; and because there are young practitioners without sufficient thera- 
peutical knowledge, and older ones with too many demands on their time, 

At 



g PREFACE TO AMERICAN EDITION. 

nicelv to test the value, and accurately to determine the doses and other 

mnortant conditions on which the efficient use of remedies so much depends. 

Mv ann has oeen, to produce a treatise on female diseases, true, simple, 

ano^nradcal which may form a safe and efficient guide to the elucidation and 

rnmtiye trea m7n t of mLy of these intricate, rapidly-progressing, and dan- 
cuiative weatmem 01 11 alone wJ1 be a sufficient 

gerous maladies, it success auenu uic ™» , endeavoured to 

° rn f or the labour I have bestowed on the work. I have endeavoured to 
wte in a plaL am) Perspicuous style, with scrupulous accuracy as to facts ; 
m din reference to opinions and treatment, nothing is recommended, the pro- 
bability or worth of which, my own experience has not confirmed. 

The y first part of my undertaking is now before the profession and in refer- 
ence to i I may say, in the words of the great and lamented Dr. Gooch 
"When an author attempts to execute his own view of a subject, he is the 
J Jerson in the world i judge whether he has «<^ d ed or fiul^W^ 
be ha* finished his book, it is impossible for him to see it in the same poim 
o> vtvfand in the same light, asVe public will; ^it tt "shld 
if he could forget its thoughts and phrases, and read it with a fresh and 
impartial mind f he may show it to a judicious and well-informed friend, but 
thisTs 1 1 pTo r thermometer of public opinion : the only one is publication, and 
to this I must trust the fate of my volume." „t,„ Hp distance 

In conclusion, I acknowledge with pleasure some valuabk »M» 
afforded me by the late Mr. Tweedie,Dr. Lever and Dr. Oldham, the Ubste 
trie Assistants of Guy's Hospital. 



Grafton Street, Bond Street, London, 
November, 1844. 



PREFACE TO THE AMERICAN EDITION. 

An apoWy would seem to be due to the American medical public for pre- 
seX/them with a work on the diseases of females at the present time ; 

but the editor of the following pages ^^^ x ^^ ex ^^^Z 
will afford a better excuse than he is able to give. They will be ^ d so 
replete with facts, so full of just observations and plain practical de ductions, 
that no medical man can peruse them without experiencing both pleasure 

an D?. r Ashwell has had most enlarged opportunities, has observed much and 
thought deeply and profitably, and in addition to these advantages evidently 
possesses a mind well stored with knowledge derived from extensive reading 
His chapters, themselves full and comprehensive, are accompanied by cases 
carefully and graphically described. Occasional notes have been appended 
to this edition, and a few cases inserted by the American editor, which he 
hopes will not be thought to mar the integrity of the work. 



CONTENTS. 



Preface to the English Edition .... 

Preface to the American Edition 

Pathology of Functional Diseases of the Uterine System 



Page 

5 

6 

13 



PART I. 



FUNCTIONAL DISEASES OF THE UTERINE SYSTEM. 



CHAPTER I. 

Chlorosis . . . . . . . .17 

Complication of, with Amenorrhcea .... 21 

Hematemesis . . . . .23.1 

Chronic Derangement of Digestion and Nutrition 23 
Functional Affection of the Cerebrum . 24 

Disorder of the Vascular System . . .26 

Ascites . . ... .26 

Structural Change of Lung . . .26 

Cases of Simple Chlorosis ...... 33 

Confirmed Chlorosis . . . . . .36 

Chlorosis, complicated with Vicarious Discharges of Blood, and 

Disorders of the Stomach and 
Bowels ... 38 

Cerebral Affection . . 43 

Functional or Structural Disease 
of the Lungs . . 45 



CHAPTER II. 



Of Amenorrhcea 
Amenorrhcea of Retention . 
Suppression 



49 
49 
56 



8 



CONTENTS. 



CaTs'o? Amenorrhoea 'dependent on Congenital Deficiency, Malforma- 
tion, or Disease of the Genital Organs . . , • 



Page 

62 
68 



CHAPTER III. 



Of Vicarious Menstruation . 

Cases of Vicarious Menstruation 



75 

78 



CHAPTER IV. 

Of Dysmenorrhea 

Irritable or Neuralgic Dysmenorrhea 

Plethoric Dysmenorrhea 

Congestive Dysmenorrhea 

Dysmenorrhea dependent on Mechanical Obstruction 

Cases of the various Kinds of Dysmenorrhea 



80 
80 

81 
82 
82 
89 



CHAPTER V. 



Formulae of Remedies 



. 93 



CHAPTER VI. 

Of Menorrhagia 

Profuse Menstruation . • • • • 

Profuse Menstruation, accompanied by direct Loss of Blood trom 

Uterine Arteries 
Acute or Active Menorrhagia .... 

Spasmodic Menorrhagia . • • 

Passive or Chronic Menorrhagia .... 

Congestive Menorrhagia . 

Cases of Spasmodic Menorrhagia .... 
Congestive Menorrhagia 



the 



101 
101 

105 
105 
107 
107 
109 
114 
115 



CHAPTER VII. 



Of LEUCORRH03A 

Common Leucorrhea 
Inveterate Chronic Leucorrhea 
Symptomatic Leucorrhea 
Peculiar Form of Leucorrhea 
Inflammation of the Cervix Uteri . 
Cases of Inveterate Leucorrhea 
Case attended by Accumulation of Pus 
Cases from M. Tealier 



• 


• 


122 
. 126 


• 


• 


128 
. 129 


• 


• 


140 
. 142 


• 


1 

• 


143 

. 146 



CONTENTS. 



CHAPTER VIII. 



Page 
Of the Disorders attendant on the Decline of Menstruation . 148 

Functional Derangements of the Brain and Nervous System . 149 

Increased Action and Congestion of different Organs . . . 150 

Lesions of Structure and Malignant Disease ' . . . 152 



CHAPTER IX. 

Formula of Remedies ..... 153 

CHAPTER X. 

Of Hysteria ..... 158 

Hysteria dependent on a Morbid State of the Uterine System . . 172 

Plethora ..... 173 

Debility . . . . .174 

Gastro-intestinal Disorder . . 175 

CHAPTER XL 

Of Irritable Uterus ... . 180 

Cases of Irritable Uterus ...... 185 



PART II. 

OF THE ORGANIC DISEASES OF THE INTERNAL AND EXTERNAL 

FEMALE GENITALS. 

• CHAPTER I. 

General Remarks on the History and Symptoms, Diagnosis, Pa- 
thology, and Prognosis of the Organic Diseases of the Uterine 

System ....... 188 

The History of the Symptoms ... 189 

Examination by Touch ... 192 

the Speculum ..... 200 

the Stethoscope . , 202 
the Discharges . . . .203 



10 



Prognosis 
Pathology 



CONTENTS. 



Page 

204 
206 



CHAPTER II. 

Of the Tumours of the Walls of the Uterus, characterized by ^ 

Induration ••••_. oii 

Tumours growing Externally, covered by Peritoneum . ■ ^ 

Internally, invested by the Uterine Mucous Lining 216 

Cases of the different Kinds of Uterine Tumours . . • ^ 



CHAPTER III. 

On Premature Labour in Pregnancy, complicated with Organic 

Diseases . 244 

Cases ...••• 



CHAPTER IV. 

Organic Diseases of the Cervix and Os Uteri 

Congestion of the Uterus . 

Acute Metritis ...» 

Chronic Metritis ...» 

Cancer of the Uterus 

Cases ..'.•• 

Of the advanced Stage of Cancer 

Of Excision of the Neck of the Uterus 

Of Extirpation of the entire Uterus . 

Simple Ulceration of the Cervix and Os Uteri 

Corroding Ulcer of the Uterus 

Cauliflower Excrescence of the Uterus 

Cases . 

Occlusion and Rigidity of the Os Uteri 

Cases of Entire Occlusion 

Contracted Os Uteri 



258 

258 

260 

261 

263 

280 

286 

295 

298 

302 

306 

308 

312 

314 

321 

323 



CHAPTER V. 

Organic Diseases of the Mucous Membrane of the Cavity of the 
Uterus .....••• 

Polypus of the Uterus . . 

Cases . • • • • 

Malignant Growths and Ulcerations of the Uterine Cavity 

Physometra, or Tympanites of the Uterus .... 

Hydrometra, or Dropsy of the Uterus .... 

Cases ...•••• 



330 
330 
345 
350 
352 
354 
362 



CONTENTS. 



11 



Abscess in the Wails of the Uterus . 

v_.<ises ....... 

Of Uterine Moles ...... 

Vesicular Moles, or Hydatids of the Uterus 

Cases n 

Osseous and Calcareous Tumours of the Cavity of the Uterus 

Phlebolites ....... 

Atrophy and Hypertrophy of the Uterus . 



Page 

364 
364 
366 
368 
373 
374 
375 
375 



CHAPTER VI. 



Displacements of the Uterus 

Relaxation, Prolapse, and Procidentia Uteri 

Inversio Uteri 

Cases ..... 

Anteversion and Anteflexion of the Uterus 

Cases ..... 

Retroversion of the Uterus 

Cases ..... 

Retroflexion of the Uterus 

Oases ..... 

Hernia of the Unimpregnated Uterus 

Cases ..... 



. 377 

377 
. 398 

410 
. 411 

415 
. 418 

431 
. 432 

433 
. 434 

435 



CHAPTER VII. 

Diseases of the Ovaries .... 

Acute Ovaritis ..... 

Chronic Ovaritis 

Dropsy of the Ovary .... 

Prognosis, Terminations, and Extirpation of the Ovary 

Cases . . . . 

Observations on Cases .... 

Organic and Malignant Diseases of the Ovary 

Atrophy of the Ovary .... 

Fibrous Tumours of the Ovary 

Malignant Diseases of the Ovary 






. 437 




438 


• 


. 441 




444 


t 


. 453 




465 


• 


. 479 




481 


• 


. 482 




482 


• 


. 483 



CHAPTER VIII. 

On the Diseases of the External Organs of Generation in the 

Female ....... 487 

Phlegmonous Inflammation of the Labia .... 487 

Encysted Tumour of the Labium ..... 488 

Oozing Tumour of the Labium ..... 489 

Warty Tumours of the Vulva ..... 490 

Inflammation of the Mucous Membrane of the Vulva . . .491 

Vulva in Adults .... 493 



12 CONTENTS. 

Page 

Eczema of the Vulva .....•• 494 

Follicular Inflammation of the Vulva . 496 

Case . . 498 

Enlargement of the Clitoris ..... 4\iy 
Vascular Tumour of the Meatus Urinarius . . . .501 

Thickening of the Cellular Membrane surrounding the Urethra . 502 
Disease of the Vagina — Prolapse of the Walls of the Vagina . 



503 



APPENDIX. 

On the Morbid Consequences of Undue Lactation . . 509 

Cases . . • • • • • 516 

Case of Pregnancy complicated with Abdominal Tumours-— Induction 
of Premature Labour ....•• 519 



A PKACTICAL TREATISE 



ON THE 



DISEASES PECULIAR TO WOMEN. 



PATHOLOGY OF FUNCTIONAL DISEASES OF THE 

UTERINE SYSTEM. 



I propose to comprise the diseases peculiar to women in two great 
divisions. In the first, I shall place the functional; and in the second, 
the organic sexual diseases. 

A few preliminary observations on the pathology of each of these 
classes may explain and illustrate what is subsequently to be advanced. 
The functional are more complicated and less easy of accurate diag- 
nosis than the structural diseases. It is often difficult to assign a pre- 
cise locality to the former, as few of them are exclusively confined 
to the uterus, but exert, through the medium of the ganglionic system 
of nerves, an extensive constitutional influence. The difficulty is not 
so great in determining the seat and degree of an organic lesion. A 
functional disease is one which is dependent on deviation from the natural 
or healthy action of any part of the organization, indicated by symptoms 
during life, which after death are found to be unconnected with discernible 
changes of structure. Contrast such a disease with cancer or scrofula 
essentially organic maladies, and the difference is striking. In the 
latter, any part which is attacked will suffer conspicuous changes of 
its texture and conformation. Functional uterine affections are mainly 
dependent on the derangement of menstruation ; such for instance as 
chlorosis, amenorrhea and dysmenorrhea, profuse menstruation, me- 
norrhagia, and m some measure leucorrhea. In all, there is a devia- 
tion rom the standard of uterine health. In chlorosis, amenorrhea 
and dysmenorrhea, there is scantiness of the catamenial secretion and 
pam, while in rnenorrhagia and its varieties there is profusion and ex- 
cess; results indicative, probably, of marked difference in the nature 
/it 



■M THE PATHOLOGY OF 

of the primary affection, both of the organic nervous system and of the 
circulation. V In health, the catamenial secretion is genera ly of the 
colour of the venous blood, perhaps slightly more florid, but less viscid 
and without the power of coagulation, never separating, as blood does, 
into its component parts, however long it may be kept. Ordinarily, 
it occurs once in every lunar month, and without pain, the process 
continuing for three, four, or five days, and the excretion amounting, in 
quantity, to three, four, or five ounces; the fluid having a faint and 
sickly, and occasionally an offensive odour, different from blood, and 
but little disposed to putrefaction. 

There is considerable variety in these particulars. Tn some women, 
menstruation is performed more, in others less frequently. In one 
individual the amount of the secretion exceeds, while in another, it tails 
short of the usual quantity, differing also in its quality or character. 
So far, however, as my observation extends, at least within certain 
limits, regularity in the periods of menstruation appears of greater im- 
portance, than either the absolute quantity or quality of the fluid. JNor 
must it be forgotten, in estimating the influence of menstruation on the 
health, that the catamenial secretion is peculiar to the female ot the 
human race. There is no analogous secretion in other animals, lneir 
uteri are neither so thick, so capable of development during pregnancy, 
nor so vascular ; nor in any of them, not even in those species of apes 
which walk nearly in the erect position, have we any proof that the 
mucus discharged during the oestrum is furnished by the uterus; it is 
thought to be almost entirely a vaginal fluid. • _ ^ 

Menstruation may with truth be said to be a function of the highest 
importance to women ; so intimately connected with the whole of their 
economy, that its partial or entire suppression may and does often 
induce serious and sometimes fatal disease. p 

It might have been supposed that there would be structural or physi- 
cal changes in the uterus, concomitant with these affections. But it is 
not so; for, if the undeveloped organization of the uterus and ovana, 
in chlorosis, be excepted, there is little discovered by post-mortem ex- 
amination, to account for these derangements. 

Even in protracted and incurable menorrhagia, which occasionally 
destroys life, by giving rise to dropsies and other secondary diseases, 
if there have been no morbid growths coexisting, the uterus will not 
yield evidence of much structural disease. An increased softness and 
paleness of its parenchyma and lining membrane, will generally com- 
prise the whole of the visible organic change. The same may be said 
of amenorrhea and dysmenorrhcea. Beyond hypertrophy and con- 
gestion in the latter affection the organization generally continues un- 
altered.* 

The local symptoms accompanying these affections, excepting dys- 
menorrhcea, are usually slight and obscure. The constitutional de- 
rangements, on the contrary, although functional and sympathetic, are 
severe and extensive. Thus, it is common in chlorosis, amenorrhcea 

* Except in those cases of dysmenorrhcea which are caused by constricted condi- 
tion of the neck of the uterus.— G. 



FUNCTIONAL DISEASES OF THE UTERINE SYSTEM. 15 

and dysmenorrhoea, as well as in menorrhagia, but particularly in the 
former, to have marked disturbance of the nervous, vascular, respira- 
tory, and digestive systems; pointing to the fact, that the womb and 
its appendages derive their nervous energy from the organic nervous 
system, while the external genitals derive their supply, almost entirely, 
from the spinal marrow. Thus are the internal and external organs 
of reproduction, in great measure, functionally independent of each 
other. Even paralysis of the lower extremities and external organs 
may exist, without a similar want of power in the conceptive faculty 
of the ovaries and uterus. 

The proximate cause of these functional maladies has excited a good 
deal of controversy. Chlorosis ought to be attributed to an impo- 
verished circulation and undeveloped ovaries. Dr. Hamilton, seeing 
that costiveness frequently precedes and accompanies chlorosis, erro- 
neously, I think, regards this state as its cause. He also denies the 
influence of the genitals on the general health, and says "that castrated 
and spayed animals suffer certain changes of constitution, but they re- 
tain the enjoyment of perfect health." Reasoning from this analogy, 
he says, "I do not understand how the influence of the female genitals 
can be so great, as that its partial suspension should occasion retention 
of the menses, or should induce chlorosis." I think Dr. Hamilton is in 
error here. In the case of castrated and spayed animals, puberty was 
either already present, or would have occurred, but for the castration. 
In early chlorosis, on the contrary, puberty is absent when it ought to 
exist, and the subsequent evils are not so much the result of the ab- 
sence or abstraction of the genital organs (for in Mr. Pott's celebrated 
case the woman lived and did well after the removal of the ovaries) 
as of the early deficiency of vital energy or power, of which the 
costiveness, equally with the chlorosis, is one of the results. This 
author overlooks, in the conservative efforts of life, when important 
organs have been taken away, the injurious and sometimes fatal con- 
sequences of such a congenital deficiency of vital power, as shall per- 
mit the reproductive apparatus to remain partially or entirely undeve- 
loped ; and who can measure the amount of the injurious effect? The 
examples, therefore, are by no means analogous. Amenorrhcea is con- 
nected with a torpid and inactive state of the generative organs, ex- 
cepting in' those cases where, from a variety of causes, marked de- 
rangement of the uterine circulation exists. Dysmenorrhoea, as a func- 
tional disease, appears to be most frequently induced by irritation more 
or less acute, by a low inflammatory state of the uterine mucous mem- 
brane, or by an active, or even slow congestion of the uterus. Me- 
norrhagia and profuse menstruation may arise from different conditions 
of the capillaries, which are sometimes over-distended from repletion; 
and at others, having lost their tone, permit the passive exudation of 
their contents. 



PART L 



FUNCTIONAL DISEASES OF THE UTERINE SYSTEM. 



CHAPTER I. 
OF CHLOROSIS. 



Definition. — A 'peculiar affection of the general health : in which debi- 
lity, languor and deranged stomachic functions are prominent symptoms ; 
most frequently occurring when puberty is or ought to be established, al- 
though it may exist at any subsequent period, always characterized by ance- 
mia of the system, and a yellowish, dirty-green pallor of the surface ; when 
a disease of early youth, almost invariably connected, either with entire ab- 
sence of menstruation, or with a scanty, painful, and irregular performance 
of the function, and if a disease of later life, in addition to these causes, 
it may have been preceded and produced by menorrhagia, or leucorrhoea. 

History and Symptoms. — In furnishing these, precision is important, 
as chlorosis presents itself in three forms : as a mild and incipient, an 
inveterate and confirmed, and a complicated disease. 

The incipient and mild form commences almost unobserved: the pa- 
tient has been, perhaps from infancy, or at least for some years pre- 
viously, delicate and feeble, so that anxiety has existed about her; 
but now, at the age of twelve, thirteen, or fourteen years — without 
any obvious exciting or morbid cause, other than a negative one, the 
non-establishment of puberty, — a series of distressing and perplexing 
symptoms are ushered in, and observation is more especially directed 
to her, because an important epoch in her life has arrived. Hitherto 
she has been delicate, but there has been probably no disease. Now 
she excites apprehension from the gradual but evident decline of her 
health, in connexion either with the entire or partial absence of men- 
struation. She does not pass on to womanhood. 

Such a patient is languid, soon fatigued, and therefore inactive; she 
is not cheerful, but dull, and listless; sometimes perverse and sullen, 
and prone to solitude. Her appetite is capricious ; it either fails alto- 
gether, or she craves for unwholesome food. Her complexion is al- 
tered; although always pale, it is now much more so; the bowels are 



jg CHLOROSIS. 

constipated, the tongue is of a dirty, pasty white, the breath is offensive ; 
she suffers from flatulence ; the slightest exertion fatigues and induces 
short breathing; frequent, severe, and peculiar headaches, palpitation ot 
the heart and pain in the side are common occurrences; the pulse is 
quick, weak, compressible, and sometimes fluttering. The catamenia, 
if not absolutely retarded, have scarcely appeared, the discharge having 
been pale in colour, and scanty in quantity. 

The symptoms already described, in an aggravated degree, and 
some new ones, attend inveterate and confirmed chlorosis. The debility, 
languor, and listlessness, are more marked. The depression is more 
complete, the appetite is more morbid, with a desire very often tor 
slate-pencil, chalk, acids, pickles, and other things equally pernicious. 
The complexion becomes still more characteristic: it is a yellowish, 
dirtv green, and the lips, gums, conjunctivae, and lining membrane of 
the mouth, are bloodless; the tongue, too, is of a still paler white, and 
being soft and flabby, it is easily indented by the teeth ; the breath is 
more offensive; there is nausea; sometimes vomiting and frequent heart- 
burn; the bowels, although generally constipated, are occasionally in 
a state of irritable and painful diarrhoea. There is acute and anoma- 
lous headache, attended by every variety of distressing sensation, such 
as heavy weight in the front or at the back of the head, vertigo, fixed 
and intense pain in one particular spot, paralytic feeling and neural- 
gia. There is a dark line underneath the eyes, about the alee of the 
nostrils and at the angles of the mouth ; the eyelids are dark and cede- 
matous in the morning; the ankles and legs are frequently so at night; 
the cellular or soft tissues are flaccid, and the surface generally, espe- 
cially of the upper and lower extremities, is cold. If menstruation 
has continued up to this time, its intervals become more distant, the 
discharge itself is very- scanty, continuing to flow only for a few 
hours, and in quality it is often serous and pale, and of offensive odour. 
There is sometimes a general dryness of surface ; the skin is no longer 
resilient; there is a splitting and brittleness of the finger-nails ; the hair 
loses its glossy brightness, falls off in large quantities, and alters in 
colour. It is not uncommon in advanced chlorosis, for the abdomen to 
be full and painful; and without decided phthisical complication, there 
may be slight, short cough, pain under the left mamma, and hysteria 
in a variety of forms. At this period, one or several symptoms being 
confirmed, so far mislead as to induce the belief, that the lung, the 
brain, the liver, or the heart may be organically diseased. Such is 
the malady when fully developed. 

Complicated chlorosis consists in the presence, in greater or less de- 
gree, of the general symptoms of the disease, with a more prominent 
morbid affection of some distinct organ or part of the system. 

Predisposing causes. — A delicate, feeble, and undeveloped constitu- 
tion, where the circulation and nervous power are inadequately exert- 
ed to perfect the organization of the body, in consequence of which 
the evolution of the ovaries is delayed, and their peculiar influence on 
the system, and particularly on the uterus, is withheld: thus, puberty 
is only imperfectly or perhaps not at all established, and menstruation, 
which must be preceded by puberty, is absent. At a later period of 



CHLOROSIS. ]9 

life, when even married women and widows are the subjects of chloro- 
sis, its predisposing cause is most frequently derangement of menstrua- 
tion; there is either retention, irregularity, or pain, and difficulty in the 
performance of the function. Nor must it be forgotten, that profuse 
menstruation, menorrhagia, and chronic leucorrhcea, may induce chlo- 
rosis. 

A damp, cold, and marshy locality, insufficient and innutritious food, 
the late hours and excitement of fashionable life, the sedentary employ- 
ments of the poor in crowded and ill-ventilated factories, where the 
temperature is high and the smells are offensive, in fact, whatever re- 
laxes and enfeebles the system, at any period of life, and especially at 
an early age, predisposes to this disease. 

Chlorosis is occasionally met with in our own sex, and I certainly 
have seen one or two marked instances of it. 

Exciting causes. — Circumstances which depress the mind, and keep 
the feelings in a state of painful suspense or delay, unrequited affection, 
an attachment which is opposed on account of its imprudence, separa- 
tion from family and friends, the sadness occasionally induced by being 
at school. Habitual constipation of the bowels, according to Dr. 
Hamilton. Amenorrhea, leucorrhcea, and menorrhagia; excessive ve- 
nereal indulgence, and manustupration, weaken the powers gene- 
rally, and especially the tone of the sexual system, and thus conduce 
to chlorotic disease. In all these causes, the impaired influence of the 
organic system of nerves may be traced, not only on the ovaries and 
uterus, but also on the organs concerned in digestion, circulation, and 
respiration. 

Pathology of chlorosis.— It may probably be fairly assumed, certainly 
it is the most^ prevalent opinion, that chlorosis primarily depends on a 
morbid condition of the blood, which secondarily affects the ovaries 
and uterus, by retarding their growth. This opinion is supported by 
the fact, that in the blood of chlorotic patients there is an increased 
proportion of the serum, with a marked diminution of the crassaraen- 
tum. This has always been my view of the disease ; nor would it be 

difficult to trace to this morbid condition of the blood, many nearly 

all the different theories which have been propounded. 

Gooch and Andral pointedly allude to the deteriorated quality of the 
blood; the former in his published lectures,* says, "If in girls who 
have attained the age at which this change is customary, the sexual 
organs are not developed, a deranged state of the constitution occurs, 
characterized by peculiar symptoms," &c— "In addition to the other 
circumstances just enumerated, the quality of the circulating fluid is, 
in chlorosis, altered; blood has been taken by way of experiment, and 
it has been found to be of a pale-red colour and watery, like the juice 
of a cherry." After thus acknowledging that the sexual organs are 
not developed, and that the blood is morbidly altered, Dr. Gooch, in- 
consistently, I think, condemns, as entirely groundless, the opinion that 
chlorosis depends on the absence of the physiological influence of the 
ovaries; and yet a little farther on, in explaining his own views, he 

» 

* Vide Gooch's Lectures by Skinner, page 7. 



20 CHLOROSIS. 

says, "that chlorosis depends on a want of that constitutional vigour, 
by which the sexual organs maybe brought into action; that to this 
deficiency may be imputed the failure both of their development and 
functions. At the period of puberty, the constitution has not only itself 
to nourish, but it must have energy to rouse and excite to action a new 
set of organs; it must supply the materials for an increase of their 
growth, and all other purposes incident to their functions." Dr. Gooch 
could not more accurately have explained the course by which the 
blood, when impaired in quality and diminished in quantity, delays pu- 
berty and menstruation, and in their stead allows the establishment of 
chlorotic disease. 

Andral's observations on the ansemia of chlorosis are so confirmatory 
of the views now expressed, that I cannot resist their entire quotation. 

"The expression,* general ansemia, if taken in its rigorous significa- 
tion, is incorrect; for the system can never suffer the total and complete 
absence of blood, without the heart ceasing to act, and the other phe- 
nomena of life becoming extinct. The term hypcemia would therefore 
be more correct. The quantity of blood in circulation may, however, 
be so diminished, as no longer to penetrate the minute vessels of the 
cutaneous surface, in which its place is supplied by a thin serous fluid ; 
and after death, a deficiency or even total absence of blood is observed, 
not only in the large arteries, veins, and right side of the heart, but like- 
wise in the capillary system, which is remarkably pale and colourless. 
In these cases the membranous and parenchymatous tissues, such as the 
brain, lungs, liver, kidneys, alimentary canal, and the parenchyma of 
the heart and muscles, are also remarkably pale and exsanguineous.' 5 

Andral again says, " In chlorosis several of the morbid phenomena 
first recorded are constantly observed ; and if this disease, as is now 
generally admitted, frequently results from a defective formation of the 
blood, the cause of which may reside exclusively in the nervous system, 
can we with any show of reason refer either to irritation or sanguineous 
congestion, the proteus-like variety of functional derangements which 
chlorotic patients so constantly present, such as epileptic paroxysms, con- 
vulsions, chorea, dyspnoea, palpitations, vomiting, &c? Or, shall we 
not approach nearer the truth, in assigning these different morbid phe- 
nomena to the same cause, which produces them in persons who are 
reduced to a state of anaemia, by the deprivation of food, light, and 
wholesome atmosphere? We may appeal to the test of experience, to 
the laedentia and iuvantia, for the further confirmation of this doctrine. 

i • ••• 1*1* 

Venesections employed in such cases to combat an irritation, which in 
reality does not exist, invariably produce a marked aggravation of all 
the symptoms; on the contrary, it frequently happens that by stimu- 
lating the nervous system of these chlorotic patients by the physical and 
moral emotions of matrimony, we produce a more natural complexion 
and colour of the whole cutaneous surface, thus indicating a correspon- 
dent improvement in the process of sanguification, and in proportion as 
the anaemia disappears under the influence of this new modification of 

* Vide Pathological Anatomy, translated by Townsend and West. Vol. i., pages 
97 and 106. 



CHLOROSIS. 



21 



the nervous system, the whole train of diseased action, the difficult 
respiration, constant sensation of uneasiness and listlessness, impaired 
digestion, gastralgia, vomiting, tympanitis and limpid urine, together 
with all the strange nervous symptoms, which seemed dependent on 
some organic alterations of the solids, gradually subside and eventually 
vanish, as a fresh supply of blood is generated'in the system." 

Diagnosis.— It will be allowed, after what has been advanced, that 
chlorosis is not an inflammatory disease. It is indeed most intimately 
connected with anaemia, and closely resembles (except in the pale green- 
ness or dinginess of the skin) that state of system which is the result 
cf hemorrhage or any undue secretion. Those symptoms, therefore, 
such as severe headache, pain in the side affecting the breathing dis' 
tressing action of the heart, and several others, must not and cannot, 
wiere proper caution is observed, be mistaken for and treated as acute 
infammatory affections. From the want of this caution, Ihave witnessed 
the very injurious consequences of such mistakes, the practitioner having 
forgotten, what in female disease it is peculiarly important to remem- 
ber, that the severity of the pain, and the rapidity of the pulse, are 
generally indications of irritability and excitement, not of inflammation ; 
demanding narcotics, carminatives, and at the most, counter-irritation,' 
not bleeding, active purgatives, or spare diet. If any definition be cor- 
rect, amenorrhcea, which may, and often does exist, quite independently 
of chlorosis, cannot be regarded as a synonymous disease. It is im- 
possible, that there should be chlorosis without more or less of amenor- 
rhcea, yet it is often seen, that there is amenorrhcea without any de- 
gree o; chlorosis. It is quite true, that when amenorrhcea has not been 
cured or relieved— when it has produced, by its long continuance, ex- 
tensive constitutional derangement— that then chlorotic symptoms' will 
appear, and that, ultimately, the series of morbid phenomena consti- 
tuting chlorosis will be clearly seen. Nor must it be forgotten, that chlo- 
rosis is itself a frequent cause of amenorrhcea, by its prevention or pro- 
traction of puberty, on which menstruation depends; and subsequently 
even when the catamenial function has been established, leading to its 
partial suspension, and occasionally toi ts entire suppression. There 
will be no difficulty in distinguishing chlorosis from chronic affections of 
the abdominal viscera, especially from hepatic, splenic, and renal dis- 
ease, or indeed from any morbid state, of which anaemia and pallor are 
prominent symptoms. The period of life, the peculiar aspect of a chlo- 
rotic patient, and the derangement of menstruation, will insure a correct 
diagnosis. 

In the complication of chlorosis with amenorrhcea, the ovaries and uterus 
are principally affected. Here the chlorosis may have existed for some 
time, preventing the complete establishment of puberty and menstrua- 
tion, but allowing both in a partial degree. After some months, when the 
function entirely ceases, there is a marked deterioration of the general 
health, and the malady becomes a double or complicated one It is 
chlorosis with amenorrhcea. Or this combination may gradually occur, 
as the result of amenorrhcea, produced slowly and insidiously, after 
months or years of healthy and natural menstruation. I need not say 
that the latter disease is rare, the other is common, and, if protracted, 



22 CHLOROSIS. 

dangerous. It is this complication with amenorrhcea which has led to 
the confusion of names ; the symptoms of menstrual suspension being so 
intimately blended with the affection of the general health, as to have 
induced, in many minds, the opinion, that chlorosis and amenorrhcea 
are convertible terms, and that they really denominate one and the same 
disease. It is almost unnecessary to add, that these are the cases 
which so frequently terminate in health, if early, well, and sedulously 
treated. Under tonic treatment especially, the blood is improved, both 
in quality and quantity; the pallor of the surface disappears; there is a 
vigour of system never before possessed ; and, prompted and sustained 
by this increased energy of the constitution, the various functions of the 
system are better performed ; puberty is more fully developed ; and thus, 
with or without the assistance of emmenagogue medicines, the catamenal 
secretion is regularly and pretty abundantly established. A few mor.ths 
demonstrate, that the transition from disease to health is at length safely, 
though tardily and with difficulty, completed. Of course, in some in- 
stances, the duration of these chlorotic and amenorrhceal complicaaons 
will be painfully protracted, and there will be an aggravated seventy of 
symptoms, productive of great alarm. In such circumstances, it will be 
necessary to redouble, not the activity of the treatment, but the care and 
watchfulness bestowed upon the patient, so that we may discern imme- 
diately any indications of farther complication ; always remembering, 
how probable it is, in this climate at least, that phthisical disease may- 
occur. 

If the malady continues, although the treatment may have bean ably 
and perse veringly pursued, parental alarm and professional anxiety will 
soon be heightened. There are instances, however, where the critical 
point in the disease may have arrived, before any treatment has been 
employed. Such maladies are prevalent, and present nothing unusual; 
delicacy of constitution and imperfect menstruation are events of every 
day ; and to the neglect and delay consequent on the commonness of the 
disease, many fatal results may be attributed. I have often, during 
the last few years, been requested to treat such patients, of whom, had 
I judged from what I heard, I should not have predicted any danger; 
and yet, on careful inquiry — and, in some instances, at first sight— I 
have been convinced that the case was all but hopeless. Chlorosis, 
combined with amenorrhcea, like other diseases, does not at once assume 
an aggravated form ; the symptoms already described exist frequently 
for a long period in a moderate degree ; and it would be wrong to deny, 
that there are cases in which, independently of treatment, the mischief 
gradually passes away. Change of air, a residence in the country, and 
more natural and out-of-door avocations, seem, by their combined influ- 
ence, to lead to the development of puberty, and subsequently of men- 
struation and good health. 

This, however, is not the usual course of events ; more frequently 
after unsuccessful treatment, and peculiarly if there be entire amenor- 
rhcea, some organ, the cerebrum, for instance, or the digestive appa- 
ratus, or the lung, becomes especially deranged ; and the functions 
dependent for their natural performance on the healthy condition of 



CHLOROSIS. 23 

this structure, are disturbed, and, to a degree, marking the fact, that 
this is the organ or part peculiarly affected. 

Complication of chlorosis with a discharge of blood from the stomach 
by vomiting. — This is not an unusual concomitant of protracted chlo- 
rosis and amenorrhea. In such cases, the treatment may have been 
partially successful. The nutritious diet, and the tonic remedies, es- 
pecially if iron has been used, may have improved both the quality 
and quantity of the circulating fluid. In this condition, the suspension 
of the catamenia continuing, congestion, or, according to the French, 
"engorgement," occurs in some of the organs of digestion and nutri- 
tion ; irregularity of gastric and intestinal action is the result; consti- 
pation, pain, spasm, and nausea harass the patient; and, in an effort 
to cough or to vomit, a quantity of dark, venous-coloured blood is 
thrown up. It often happens, that these discharges observe a catame- 
nial period, recurring every three or four weeks;* there being in the 
intervals more or less of leucorrhceal secretion. I have seen patients 
alarmingly aneerniated by these hemorrhages, especially where the ame- 
norrhcea has been of long standing, and where it has been greatly 
neglected. It is sometimes perplexing to determine whether the blood 
comes from the stomach, the lungs, or the mucous surface of the fauces 
and trachea ; its quantity and colour will generally determine this point, 
although there are cases, where pulmonary bleeding is extensive, and 
where, from some quantity of the blood having been swallowed, and 
again rejected, by vomiting, it has acquired a dark hue and a clotted 
form, involving the point in still more difficulty. Doubt will not, how- 
ever, be of long continuance; if the bleeding be pulmonary, there will 
be a prevalent cough, and a series of symptoms plainly denoting dis- 
ease of the lungs. It is scarcely necessary to observe, that local em- 
menagogues are here peculiarly useful; the quantity of the blood is 
increased sufficiently to allow of the advantageous elimination of the 
menstrual secretion; and every effort must be employed to establish 
the function. Nor is it irrelevant to remark, that persevering and ac- 
tive treatment is generally successful, where the bleeding is not pul- 
monary; and I have seen two cases, where the hemorrhage has been 
large, and from the lungs, both of which yielded to persevering ma- 
nagement. 

Complication of chlorosis with chronic derangement of digestion and 
nutrition. — In the milder form, there is always some disorder of these 
functions; but in its aggravated degree it demands much professional 
attention. 

In these cases, we do not wonder at the emaciation which may have 
occurred ; our only surprise is, that the functions of life should not have 
been even more interfered with. Patients in this condition eat scarcely 
anything; and the little they do swallow, is generally of the worst and 
least nutritious kind. I am aware, that families and medical men are 
occasionally deceived on this point; but I am also persuaded, that in 
many instances, where I have been consulted, there has been no fraud, 
the patients not having obtained food surreptitiously: and I may be al- 

* Vide Chapter on Vicarious Menstruation. 



24 CHLOROSIS. 



lowed to remark, that although medical scrutiny and acuteness are 
never more useful than in these cases, yet that it is unwise and unkind 
to express a suspicion of this sort, without some tolerable proot. It is 
interesting to trace and to watch this complication. An impression 
every now and then exists, that such a patient cannot recover : she 
takes so little; her strength is so impaired; the whole system is so 
emaciated, that she seems only to wait for some favouring circum- 
stances to induce phthisis; and if she be hereditarily or constitu , ion- 
ally predisposed to this fatal malady, the probability is that she will not 
escape it. And yet I know of no combination of chlorosis which at- 
fords such ample scope and reward to judicious, persevering, and ob- 
servant treatment. It is rare for a structural change to occur in he 
stomach, liver, or intestinal organs, in the most protracted form ot the 
disease, although it is common to see the largest amount of functional 
derangement. Nor are the attendant evils only physical. Ihe mind, 
the disposition, the temper, are all disturbed. Gloom and despondency, 
ennui, irritability, and dissatisfied feeling, oft-times exert an irresistible 
control over such patients; and when their present state is compared 
with what they were twelve or fifteen months previously, the contrast 
is lamentable indeed. Seclusion and solitary habits are frequently in- 
dulged, and require the watchfulness and penetration of the physician 
and the family. Nor are instances wanting, in which mental pecu- 
liarity has for a time assumed not only the appearance but the reality 
of insane aberration. Such individuals are seldom the subjects ot 
high excitement ; they are rarely violently insane. More frequently, 
they are in error on a few points only ; or, giving up all for lost, as to 
their recovery, they indulge in depression and despair. It is unneces- 
sary, minutely to describe the various indications of digestive disorder. 
They are so common, that they must be well understood. Nor can it 
be too strongly urged, that disorder of the general health, on which, 
perhaps, delayed puberty depends, and to which menstrual irregularity 
and suspension may be so often traced, is most intimately connected 
with the condition of the alimentary canal, and of the organs subsidiary 
to digestion ; and if the peculiarities of the constitution, already pointed 
out, together with puberty and menstruation, especially modify the fe- 
male economy, it may be allowed that the state of the digestive or- 
gans exercises a more extensive and peculiar power in them, than in 

our own sex. 

Complication of chlorosis with functional affection of the cerebrum.-— 
There is scarcely any complication more difficult to relieve than this. 
The varieties, as to situation, and the different degrees of intensity of 
the pain, are worthy of observation. In some individuals, the uneasi- 
ness of the head is general, but not severe; while in others, the site of 
the pain is limited, and so agonizingly intense, as scarcely to be en- 
dured. In not a few instances, the pain is periodical, and of neuralgic 
severity, while in others, it is so nearly constant, as to preclude men- 
tal or physical exertion, and almost to induce the belief that it must be 
connected with organic affection. Nor is it very uncommon to meet 
with fits of hysteria, chorea, and epilepsy attributed by the patients 
themselves, and perhaps correctly, to the long-continued and painful 



CHLOROSIS. 



25 



affections of the head. These diversified degrees of suffering will, of 
course, be associated with a variety of morbid cerebral sensations : in 
some, there will be vertigo; in others, an overwhelming sense of 
weight. At one time, there will be paralytic sensations about the head 
and upper extremities ; at another, a painful quickness of sensibility ; 
and with many of these feelings, there will be morbid sympathy, of 
the stomach especially, as well as of the digestive organs and alimen- 
tary canal. Let it only be remembered, how these morbid actions 
will become blended, how irregularly and extensively they will affect 
the entire system, and it will not be difficult to conceive of the tedium 
and misery which these patients endure. It is consolatory to know, 
that, in by far the majority of individuals thus suffering, the affection 
of the cerebrum is functional, there is rarely structural disease ; and 
if pressed for proof of this opinion, we may point to the numerous in- 
stances of recovery, even when the symptoms seemed clearly to indi- 
cate organic affection. 

It is nearly impossible, within reasonable space, to describe the dis- 
tressing and intricate morbid results attendant on this complication. 
There are, however, as already stated, not only shades of difference 
in the amount of suffering, but marked extremes : and I know nothing 
worse than the aggravated cephalalgia peculiar to this disease : to call 
it a nervous or a sick headache, even of the worst kind, gives only a 
faint idea of the intensity of the evil ; for I have heard many patients 
deliberately declare, that life would be undesirable, were it to be con- 
tinued in association with this sad infliction. Temporary loss of me- 
mory and acuteness of perception, physical irritability, torpor, and de- 
rangement of the organs of digestion, are amongst its most common 
consequences. Yet it is important to know, that there are, in most 
cases, limits, within which the morbid influence is confined, there are 
functions, with which, even in this amount of suffering, it does not greatly 
interfere. Such patients sleep tolerably well ; their appetite is capri- 
cious, but not wholly destroyed ; and, although nutrition is imperfect, 
there is not much or rapid emaciation — a circumstance in decided 
contrast with what is seen in chlorosis complicated with organic pul- 
monary change. It is not meant to be stated, that structural alteration 
never occurs, nor that ultimate recovery from the headache is invaria- 
ble and certain. But, after having treated many of these diseases, 
and afterwards having watched them for a considerable time, I am 
disposed to believe that the cerebral structures, for the most part, re- 
main unchanged ; and that the cephalalgia of many months, and, in 
some rare cases, of years' continuance, is eventually completely lost, 
provided puberty and menstruation are fully established. The cere- 
bral affections attendant on epilepsy must be expected from this state- 
ment, and, perhaps, that highly-nervous and paralytic tremor or 
shaking, which is sometimes the consequence of very protracted 
chlorosis. Again, it must be remembered, that even epilepsy may oc- 
cur without structural lesion, and that paralysis may sometimes be 
cured. There are two cases (Nos. 10 and 11) illustrative of these 
opinions, and confirmatory of the extraordinary curative effects at- 
tendant on the development or restoration of the sexual function. 



o,> CHLOROSIS. 



The vascular system, especially the capillaries and the heart is fre- 
quently implicated in protracted chlorosis ; and, by patients and the.r 
immediate friends, such complications are viewed with much appre- 
hension. Constipated bowels and severe headache are common c.r- 
cumtances- but the entire loss of the natural colour of the surface, 
«d"ma of the face and extremities, palpitation of the heart and syn- 
cope, are less frequent, and wear so formidable an aspect, as to ex- 

cite great alarm. , . c ^ ^ • . 

Ascites, I have rarely seen connected with the oedema of chlorous 
certainly not in early life : at a more advanced period, derangement 
and structural change of the liver or kidneys may combined with 
chlorosis, induce effusion into the peritoneal sac. Such events are, 
however rare. No doubt ascites in diminished quantity does occur, 
in the general tendency to serous effusion, which is so marked, when 
chlorosis is protracted; but it is not a formidable symptom in itself, 
and vields to the remedies which would improve the quality of the 
blood When, however, the effusion is in greater amount, distending 
the abdomen; structural disease of the liver or kidney, as already ob- 
served, will be found to exist, when only, palliative remedies can be 
empWd. It is right also to caution the attendant and the family, 
against supposing that every hue of the surface, slightly more icterode 
than usual, is to be regarded as an indication that the liver is seriously 
deranged, and requires for its restoration mercurial remedies. 

Complication of chlorosis with structural change of the lam. — 1 he ma- 
lady rarely terminates fatally, except in combination with phthisis, 
and the question is not unimportant, whether the phthisis be induced by 
it and amenorrhcea; or whether these latter affections do not owe their 
origin, at least in part, to the original phthisical tendency of the system 
This predisposition may be dormant till the epoch of puberty ; and 
then its injurious influence may pervade the entire system. One ot 
the immediate results will be a want of energy— an imperfect develop- 
ment of the sexual character; and this failure of puberty will lead to 
chlorosis and amenorrhcea. These latter affections will be the promi- 
nent, but not the real disease. Yet it is not astonishing that the chlo- 
rosis should principally arrest medical attention: it is the ma ady pe- 
culiar to the age : there are only few and slightly-marked indications 
of phthisis: and these, and even much worse symptoms, would be 
viewed as within the scope of the curative influence of menstruation. 

Occasionally, phthisis may be induced by chlorosis and amenor- 
rhcea; but, in by far the greater number of instances, the chlorosis only 
excites into activity the previously latent tendency to this fatal dis- 
ease ; __ an opinion which receives confirmation from the fact of the 
other complications rarely passing into this. There may have been 
extensive vicarious hemorrhage, excessive and long-continued leu- 
corrhceal secretion, intense pain of the head, hysterical and even 
epileptic seizures, a highly morbid condition of the digestive or- 
gans, and a moderate degree of emaciation ; and yet there shall be no 
phthisis. The individual shall recover from these morbid states, 
without even an apprehension of consumption : — nay more, there may 



CHLOROSIS. 



27 



be fearful protraction of these maladies, and yet there shall not be 
cough, pain in the side, or expectoration ; so distinct is the line of de- 
marcation between this and the other complications. From what I 
have seen, I am convinced that structural disease of the lung is most 
frequently connected, either with chlorosis alone, or with chlorosis in 
connexion with amenorrhcea. For instance : a girl of consumptive 
family, arriving at the age of puberty, becomes slightly chlorotic ; and 
soon, instead of the negatively morbid state which may have existed 
up to this period, there creeps on slowly, but certainly, a confirmation 
of the disease;— there is no menstruation; or, if the function be de- 
veloped, it is only once or twice, and very imperfectly. Then, there 
is great cause for apprehension, not that the series of symptoms be- 
longing to the other complications will occur, but rather that the 
anaemia and want of constitutional power will favour the predisposi- 
tion to structural pulmonary change : such patients are not altoo-ether 
without appetite, the derangements of the stomach and the alimentary 
canal are not prominent symptoms, the cerebrum does not painfully 
sympathise, and frequently there is an entire absence of hysteria ■ but 
there is quickness of pulse ; irregular action of the heart ; rapidity and 
difficulty of respiration ; more or less thoracic pain, frequently con- 
fined to the left side; a short, hacking cough, and emaciation. In- 
quire particularly, and it will sometimes be found, that there is, in slight 
degree, both expectoration and perspiration. When patients have ar- 
rived so far, and sometimes, happily, before they have reached this 
point, apprehension is roused, and medical treatment is eagerly sought. 
Many such cases are occurring; and I wish the attention of prac- 
titioners to be particularly directed to this complication. The vicis- 
situdes of an English climate predispose to phthisical disease ; and 
with the physiological circumstances peculiar to the sex, explain how 
it is, that girls so frequently die,.. at this epoch, of phthisis— in con- 
nexion with chlorosis and amenorrhoea. If asked what such a series 
of symptoms as I have just enumerated indicate, the reply must be 
chlorosis complicated with a tendency to phthisis. And if it be in- 
quired, what is the chance of entire recovery, a very guarded answer 
must be given. 

To say that patients advanced thus far never recover, would be 
untrue: although it is perfectly right, to give a doubtful opinion. If 
the constitutional power can be augmented, if the blood can be im- 
proved m quality, and increased in quantity, then the symptoms may 
be arrested, and renovation of health may be slowly effected A 
symptom of improvement, of great value, is, diminution in the rapidity 
of the pulse : for so long as the pulse beats 130, 120, or even 110 in 
the minute, it must not be supposed that any real amelioration has 
taken place. It will be necessary, also, to be guarded in the opinion 
we ourselves form : the same self-delusion exists here, as in phthisis at 
other periods. The patient is convinced, there is no occasion for 
alarm ; and the disease often creeps on so insidiously, as to lead the 
family to believe, that there is no immediate danger. Let it, however, 
be remembered, that so long as there is a rapid pulse, short hacking 
cough, and a want of nutrition, there is a real hazard. If, on the con- 



28 



CHLOROSIS. 



trary, the pulse becomes slower, fuller, and softer-if the cough be less 
frequent— if the pyrexia disappear-and especially, if the patient gather 
flesh in ever so trivial a degree— hope may be entertained. 

Carefully treat such an individual : avoid mercury, drastic purga- 
tives, and emmenagogues. Place her in the country where she shall 
breathe pure air : let her diet be simple and nutritious (milk and animal 
food) and her medicine some of the various tonics ; and the expecta- 
tion may be cherished, that the time is not far distant, when the 
sexual character will be fully developed, and the danger safely passed. 
From what has been stated, it must not be inferred, that this is the 
only fatal complication of chlorosis ; but, comparatively, it is rare for 
the others to terminate unfavourably. Still, after continued derange- 
ment of the viscera of nutrition and digestion, the debility, pyrexia, and 
emaciation may become intimately blended with alteration of the pul- 
monary structure ; and the cough, expectoration and morning perspi- 
rations, may become prominently influential, in bringing about final 

Sl Vhave thus attempted to distinguish the morbid circumstances 
appertaining to the different forms of this prevalent malady. And 
although the leading and distinctive features will generally enable us 
to determine the complication, still, when any form of the disease has 
become aggravated, severe and of long duration, the blending of symp- 
toms may perplex the diagnosis, It ought to be remarked, that leu- 
corrhcea, in various degrees, is an almost constant attendant on chlo- 
rosis and amenorrhcea ; and, when excessive, so seriously impairs the 
restorative powers, as to render the cure long and difficult. 

I wish to particularize, as correctly as I can, the ages at which 
these various complications most frequently occur. Chlorosis alone, 
independently of amenorrhcea, is a disease of early life. In conjunc- 
tion with menstrual suspension, it may be met with at any period, be- 
tween the ages of puberty and the final cessation of the catamenia. 
Chlorosis conjoined with phthisis, may be seen between puberty and 
thirty years of age ; sometimes later ; but such instances are very 
rare, in comparison with the numerous complications of this kmd, be- 
fore' the attainment of the twentieth year. Again, chlorosis with 
amenorrhcea or phthisis, at an early age, are forms of the malady, 
generally associated with debility and delicacy of system ; while the 
other complications may exist at any period, and are not unfrequently 
combined with plethora or congestion. 

Treatment of chlorosis.— The treatment of chlorosis, to be exten- 
sively successful, must be early and most sedulously prosecuted. 

It cannot have escaped observation, that the disease is one of almost 
universal influence : it is not confined to a particular organ, but affects 
the entire system : and yet it is often productive of so much functional 
derangement, of so many isolated and painful affections, as to demand 
local treatment; which, while it shall be in complete accordance with 
the main principles of the cure, shall still be especially directed to ame- 
liorate topical pain. 

The reader, then, will be prepared for a classification of the means 
of cure ; — an arrangement necessary, not only to prevent confusion 



CHLOROSIS. 29 

and disappointment, but equally so for the attainment of that correct 
view of the malady itself, and of the particular stage which it may 
hare reached, on which will depend the peculiar fitness of the whole 
treatment. 

Thus, first, in mild chlorosis, either alone or complicated with ame- 
norrhoea, the remedies will be principally of a constitutional kind, 
directed to the improvement of the general health, and to the esta- 
blishment of puberty. If, when these points are gained, the uterine 
functions are not developed, the delay may perhaps be attributed to 
torpor of the organs of reproduction, and emmenagogues may be em- 
ployed. 

Secondly, when the disease is variously complicated, it often happens, 
that the^ organ, or part of the system principally implicated, becomes 
so prominently morbid, as almost to throw into the shade the original 
chlorosis and its accompanying amenorrhcea: but it must never be 
forgotten, that these have been the source of the complications, the 
soil in which they have sprung up. Here the treatment will require 
modification: it will, of necessity, be less constitutional, and must as- 
sume more of a topical and symptomatic character. 

And, lastly, where structural alteration of the lung is threatened or 
suspected, the management must have especial and almost exclusive 
reference to this alarming complication ; every measure being adopted 
to avert this greatest of all dangers. Still, even here, it must not be 
forgotten, that if puberty could be sufficiently developed to allow of 
eyen the partial establishment of menstruation, a very formidable fea- 
ture of the complication would disappear. 

It is evident, that a combination of means is required ; medicine* 
alone, cannot accomplish all; and other measures, without medicine, 
will generally fail. Again, if it be remembered, that the disease is 
proteiform and of ever-varying degree, it will be seen, that constant 
and unwearied efforts are required, not only to vary the old, but to 
suggest new resources. 

The treatment of the most common form of chlorosis, namely, that 
accompanying puberty, may be regarded as the type of the treatment 
of all the others; embodying the principles, which, with greater or 
less modification, are universally applicable. It is here, at the very 
threshold of the disease, when its character is not understood, or when 
it is treated empirically, that the greatest error is committed. It is 
viewed as a local, not as a constitutional affection ; and many are the 
individuals who have been sacrificed to the vain and ignorant attempt 
of prematurely establishing menstruation; mercury, drastic purgatives, 
and emmenagogues, having irretrievably destroyed the constitutional 
power and paved the way for phthisical disease. 

It is not my intention elaborately to comment upon certain great 
mistakes in the physical education of female youth. And yet, I must 
be excused, if I direct attention to the diet, air, exercise, and clothing 
of the sex. It will readily be granted, that if, in these particulars,, 
there is extensive deviation from the dictates of nature and common 
sense, there must be a proportionate risk of debility and disease. In 
our own changeable climate, it behooves the guardian of female youth. 
o 



3Q CHLOROSIS. 

to be especially prudent ; and I am one of those who think, that it is 
scarcely possible to study these matters too closely If the national 
practices in these particulars could be changed --and the remark ap- 
plies with great force to the middle and higher classes of society 
living in cities and towns -chlorosis, imperfect puberty, and amenor- 
rhea would be uncommon, instead of being, as they now are, extremely 

prevalent diseases. . , , 

Chlorosis is a rare affection in rural districts; where female youth 
are much in the open air, where it is not unfashionable to walk and 
run, and where it is not considered a gross violation of good breeding 
to sport and play with activity and vigour. Such girls acquire energy 
of system, each organ is developed, the blood is abundant and of ex- 
cellent quality; nutrition is healthy, and puberty is attained without 

dl Th U ese" remarks may serve as an illustration of the principles on 
which the treatment of simple and amenorrhceal chlorosis must be con- 
ducted ; and while it is scarcely possible to present a succinctand spe- 
cific history of the pathology of this and the other complications, it is 
not difficult to describe, with simplicity and tolerable accuracy, the 
order of morbid events and the medicinal means, by which they are to 
be relieved if not cured. ' . 

I have already observed, that a morbid state of the blood, of which 
anaemia is'the prominent feature, lies at the basis of the disease, lnis 
may be viewed as the clew, by which the intricacy of the symptoms 
may be unravelled: and it will equally explain the nature of the ma- 
lady, whether the specific morbid impression be in the system gene- 
rally, in an isolated organ, a particular texture, or in any of the fluids 
of the animal economy. 

But, to be more precise: — I would commence the treatment, by 
special attention to the digestive organs and alimentary canal ; for I 
regard the disorder of these, as second only in pernicious effect to the 
peculiarity of constitution, already mentioned. Nor will the advan- 
tage of their improved condition be limited to themselves; the deterio- 
rated quality of the blood and its defective quantity, may both owe 
their origin to impaired digestion and nutrition. I have already al- 
luded to & the jaundiced hue of the complexion and of the surface gene- 
rally, as leading to the suspicion of hepatic disease. The diagnosis 
will be made, by a careful examination of the region of the liver itself, 
of the urine and the faeces; which will prevent the possibility of being 
misled by the colour of the lips and conjunctivae. 

At first, then, a due evacuation of the bowels must be daily secured ; 
and much will depend on the kind of medicine by which this is effected. 
If mercury and drastic purgatives be frequently and largely employed, 
intestinal irritation will ensue, evidenced by unhealthy and undigested 
motions, mixed with mucus, and occasionally with blood. If the 
purging be excessive— if it be exclusively relied on for the cure — 
debility and exhaustion will result, and, in place of amelioration, the 
whole of the symptoms will become aggravated and severe. The 
best aperients are aloes, rhubarb, the sulphate of soda and ^manna, 
and, if an alterative be necessary, the hydrargyrum cum creta. Nor 



CHLOROSIS. 31 

must we forget, that an jnjection of a pint of warm water, two or 
three times a-week, into the rectum, is, of all measures, the most effi- 
cacious in aiding peristaltic action, and in removing the load of the 
large intestines. The compound decoction of aloes with the com- 
pound tincture of cardamoms ; the compound aloetic pill with the oil 
of cassia and hyoscyamus, and the vinum aloes with the compound 
tincture of rhubarb, are the forms of these medicines I prescribe. 
The combination, with any purgatives or aperient remedies, of mild 
cordials, is exceedingly important. The following may be advan- 
tageously exhibited : — 

Pulv. Rhei 3ss. Magnes. Subcarb. ^ss. Conf. aroin. 9i. Aquae Cin- 
namomi 3ix. Tinct. Card. C. 3i. M. ft. Haust. bis terve in septimana 
sumendus. 
Sodas Sulphatis vel Magnes. Sulphatis giss. Pulv. Rhei 3ij. Magnes. 
Subcarb. Sodas Subcarb. aa 3iij. Pulv. aromatici 3ss. M. ft. Pulv. 
aperiens. 
Sumat Coch. i. vel. ij. parva, bis terve in septimana, ex aqua pura. 
It is superfluous, perhaps, to observe, that warm clothing, regular 
exercise, by walking, if it can be borne, if not, on horseback, are 
valuable auxiliaries ; and, so soon as the repugnance to them can be 
conquered, nutritious animal diet and mild malt liquor will be produc- 
tive of benefit. The improvement of the digestive organs, indicated 
by return of appetite and the natural and daily evacuation of the 
bowels, are generally accompanied by alteration of the complexion, 
and by the partial disappearance of the chlorotic hue ; rarely by the 
immediate establishment or return of the catamenial secretion. At 
this crisis, some of the preparations of iron may be exhibited ; and the 
sulphate is probably the most efficacious, and possesses more specific 
properties than any of the rest. If the order of procedure, now pointed 
out, be reversed — if the iron be used before the bowels have been 
freely evacuated and their functional action improved, or while the 
tongue is loaded and foul, — aggravation of symptoms will be produced ; 
while, if there be only the peculiar debility and pallor, then the iron 
may be most beneficially tried. A single grain, or even two, may be 
given, twice or three times daily, combined with extract of hop, aro- 
matic confection, and a single grain of extract of poppy or hyoscy- 
amus. Occasionally, the effect of the iron is almost magical, espe- 
cially where it does not confine the bowels nor induce febrile heat. 
The following form may be prescribed: — 

Ferri Ammon. Jiss. Extr. Humuli, Extr. Papav. alb. aa gr. xv. 
01. Cassias m. xv. M. ft. pil. xxiv. Sumat. i. velij. bis terve quotidie. 
Where there is torpor of the system, flatulence, and hysterical de- 
pression, a teaspoonful of the annexed mixture, in water, may be 
swallowed with each dose of the pills : — 

Tinct. Humuli, Calumbas vel Gent. C. giss. Tinct. Lyttse 3i. Sp. Am- 
mon. arom. 3iij- ft. Mist. 
It is impossible minutely to describe every circumstance which 
may require medical management : in a lecture, much more may be 
accomplished. Still, we must keep constantly in view the peculiarity 
and the anaemia of the chlorosis itself. It will not, then, be difficult 



32 CHLOROSIS. 

to vary and modify the treatment. In some instances, iron cannot be 
exhibited, or it may have been too early used : it may not have been 
employed in the right dose, or in the most desirable form. These, 
and numberless other minutiae, demand sedulous attention. Quinine 
and sarsaparilla, gentian and zinc, are remedies of acknowledged 
power : and in a variety of instances, where the sulphate and other 
preparations of iron were injurious, I have given, with decidedly good 
effect, the following powder, either once or twice a-day :— 

Ferr. Subcarb. gr. viij. Pulv. Ipecac, gr. i. Hydr. cum Creta gr. ij. 
M. ft. Pulv. 
I have already alluded to the necessity for continued care in the pro- 
gress of the treatment ; and the hope of cure must rest, not on the vigi- 
lance of a week, but on the perseverance and skill which shall keep m 
activity, for months, every part of the prescribed plan ; not only the 
medicinal but likewise that which depends on air, regimen, and active 
exercise. I do not dwell on the value of travelling ; because it is univer- 
sally admitted, that nothing contributes more to cheerfulness and health, 
than change of scene, of air, and of temperature. Chalybeate waters are 
sometimes extraordinarily efficacious ; and a sea voyage has, within 
my own knowledge, been productive of entire cure, not only completing 
puberty but leading to perfect menstruation. — At what time shall em- 
menagogues be employed ? When the health is so far improved, that 
there is less pallor, regularity of bowels, and more and better blood. 
Iron itself, is often an efficient emmenagogue. The use, every night, 
of the hip mustard bath and the local salt shower bath across the loins, 
topically affects the uterus, and induces the catamenial secretion. The 
ammoniacal injection, composed of one drachm of the pure liquor ammo- 
nice to a pint of milk, daily injected into the vagina, has proved efficient 
in the hospital. 

I am not aware that any variation in this plan will be required in 
chlorosis complicated with amenorrhcea. Caution will be most needed 
in the selection of the time for the use of emmenagogues : but after 
what has been said now, and what is to be said hereafter, the reader 
cannot remain long in doubt. 

The iodide of iron has been extensively tried, both in hospital and 
private practice, and with undoubted success; especially when glandular 
enlargements and other indications of a strumous habit, have been as- 
sociated with the chlorosis. I give it in the subjoined form : — 

Ferri Iodidi gr. xvi. Tinct. Calumbse vel Gent. C. §i. Aquae destillatae 
£vij. ft. Mist. Sumat coch. ii. magna, bis terve quotidie. 

Three or four leeches have been applied to the mammae, on alternate 
days, with very doubtful effect as to the restoration of the menstrual 
function : nor can I speak more favourably of the employment, to the 
same organs, of mustard cataplasms. Marriage frequently cures chlo- 
rosis and amenorrhcea : yet its good effects are not certain and invari- 
able ; nor is it uncommon to witness the aggravated forms of the malady 
in married life. A passing allusion is all that is necessary on its reme- 
dial influence ; as in the chlorosis of early life, such a connexion is un- 
likely and distant, and even at later periods, its existence is not a matter 



CHLOROSIS. 33 

for medical discussion or control. Electricity deserves to be mentioned, 
as a local uterine stimulant ; and I have seen many cases where its ef- 
ficacy was decided. 

The complications of chlorosis require extended and scrutinising in- 
vestigation ; and perhaps enough has not been said of hysteria and 
chorea, as to its combinations. The former, in differing degrees, is an 
almost invariable attendant on the malady; while chorea is rarely seen 
after twenty, and seldom after sixteen or seventeen years of age. The 
observations on the treatment of the various complications will be ap- 
pended to the illustrative cases. By this method, the cases themselves 
will be rendered more interesting, and their peculiarities and plan of 
management more distinct and prominent. 

In conclusion, let it be remembered, that the progress of these affec- 
tions is often interrupted ; domestic occurrences of a vexatious or painful 
kind produce frequent relapses ; and the family, as well as the patient, 
despond. Repeated attacks of cold, errors of diet, and a neglect of 
especial attention to the evacuation of the bowels, may be enumerated as 
the causes of delay. These, the address and practical skill of the at- 
tendant must control : and it is no slight tribute to his worth in such pro- 
tracted cases, that the confidence of the invalid and of her friends is con- 
tinued to him unimpaired. He must repeatedly urge, that while there 
is only one consistent method by which recovery can be accomplished, 
there are almost innumerable ways by which a simple case may assume 
an inveterate or complicated form. 



CASES OF SIMPLE CHLOROSIS. 

MANY OF THESE AND THE SUBSEQUENT CASES WERE REPORTED BY THE GENTLEMEN 
OFFICIATING AS CLINICAL CLERKS AT GUY 7 S HOSPITAL. 

Case 1. 

Mary , aged 14, an out-patient (under Dr. Ashwell's care), January 6, 1835, 

is stated by her mother to have been from birth a delicate, sickly girl, and frequently 
the subject of cough with mucous expectoration and pain in "the left side. Her 
symptoms are entirely chlorotic. There is pallor of countenance, coldness of sur- 
face and especially of the lower extremities, lividity of the hands and of the tips of 
the fingers, and emaciation. Puberty appears partially established, as there is 
some development of the mammas; the pulse is 120 and feeble; respiration quick 
and short; cough distressing at night with slight mucous expectoration; the bowels 
generally constipated, but occasionally purged ; appetite capricious, dislikes all ani- 
mal food, is fond of pastry, tea, and bread and butter. She is one of nine children, 
two of whom are girls and older than herself, and in both, the same symptoms have 
attended the establishment of puberty and menstruation. The tongue is loaded and 
tumid, and the mucous lining of the mouth is pallid and indented by the teeth. She 
resides in a confined narrow street, and sleeps in a small room, in which are three 
beds. There is at times a slight leucorrhoeal discharge ; the urine is scanty and 
high-coloured. 

Pil. Rhei. c. gr. v. omni nocte hora somni. 
Julep. Amnion, cum Magnes. 51. bis quotidie. 
To live on beef-tea and arrow-root, and if possible, to be removed to a 
healthier residence. 



34 CHLOROSIS. 

Jan. 16. Her mother states that she caught cold when last out, but she thinks 
her bowels more regular. She is to continue the remedies. 

26 The bowels are regularly and more healthily acted upon J the pallor is less, 
and the pulse does not exceed 98, fuller and softer; the tongue is nearly clean. 

She is to continue the ammoniacal julep with magnesia two or three times weekly ; 
and to take the following mixture : — 

Ferri Iod. gr. xviij. Tinct. Calumbse gi. _ Aquae destillatse |vij. ft. 
Mistura. Sumat coch. i. magnum ter quotidie. 

A pint of mild ale daily, and animal food. 

Feb. 10. Is crreatly improved ; complains of headache and throbbing of the temple ; 
pulse 80, and full : bowels rather confined. Is to omit the iron for a few days ; and 
to take ten grains of the colocynth and calomel pill every other night. 

17. TheTbowels are quite regular ; the cerebral symptoms are alleviated ; but she 
complains of languor and debility. 

Rep. Mist, et Cerevisia ut antea. 

Julep. Ammon. cum Magnesia gi. bis quotidie. 

Is ordered to go in the country, and to be out much in the open air. 

March 1. Is better in every respect ; and is now requested, in addition to the 
remedies, to use the mustard hip-bath every night. 

8. Has menstruated for three days, with little previous indisposition ; and is so 
greatly improved, as not to require further treatment. 

Case 2. 

reported by the clinical clerk. 

J ANE , aged 19, a native of London, a girl of ordinary stature, light hair, fair 

complexion, and brown eyes. Admitted May 2. She began to menstruate at 16 years 
of age, and has regularly observed a period of three weeks, until within the last two 
months. The only peculiarity connected with the catamenia, has been the light co- 
lour of the discharge. Her situation, as a house-maid, exposed her to very irregular 
hours; and her enumeration of the symptoms which attacked her, when in this ca- 
pacity, seems to indicate the commencement of disorder of the general health. She 
suffered from headache, pains in the side, languor, and restlessness, which were suc- 
ceeded, in two months, by a suppression of the catamenial discharge. Since this time, 
her disorder has increased, and she now presents the following symptoms: — The sur- 
face is uniformly of a very light-yellow colour, and, in parts, assumes an icterode hue. 
Around the eyes, there is a darkened areola, and the integuments appear puffy. The 
prolabia, with the gums and the mucous membrane of the month and fauces, are ex- 
sanguineous. Tongue flabby, with indentations from the molar teeth on each side. 
The nails are brittle and the cuticle around them peels off. The legs are free from 
swelling. She experiences considerable dyspnoea on any slight exertion, and is very 
susceptible of fatigue. The appetite is capricious, but she has not manifested any 
particularly vitiated taste. Bowels naturally costive. The pulsations of the heart 
are loud, and the pulse full. No leucorrhrea. There is no fixed pain in any part of 
the abdomen. 

Colocynth cum Cal. gr. v. statim. 

May 6. Bowels well open. There is very little difference in the character of her 
symptoms, and the general surface remains pallid. There is a slight leucorrhceal 
discharge. A bellows sound accompanies the heart's pulsations. 

Ferri Iodidi gr. xvi. Tinct. Calumb. gi. Aq. ^vij. Cap. cochl. ij. mag- 
na bis die. 
Habeat Cerevisise Oct. ss. quotidie. 

She was kept on this tonic plan, with occasional aperients and daily exercise, until 
the end of the month. At this time she felt considerably improved. Appetite good ; 
secretions natural ; countenance still pale, although the yellow colour and dark areola 
had disappeared. At her request, she was presented. A week after her departure 



CHLOROSIS. 35 

from the hospital, under the same treatment, the catamenia returned, and her counte- 
nance assumed a more ruddy aspect. 



Case 3. 

reported by mr. henry oldham. 

HabrietS — , ao-ed 18; a girl of strumous diathesis; short; thin made, and 

rather inclined to emaciation. Admitted May 11. She was born in London; where 
she has continued to reside, being in service as a house-maid. She has always been 
delicate, but has not been the subject of any particular illness. She began to menstruate 
at 16 years of age, but has never accurately observed the regular periods. About 
five months ago the catamenia became suppressed, and have failed to appear since 
that time. This seems to be the date of her present illness. She now complains of 
fluctuating pains about the chest, left side, and back; sometimes in the loins, and 
which occasionally proceed down the thighs. She suffers severe headache, giddiness, 
vertigo, muscse volitantes, singing noise in the ears, with other symptoms of imperfect 
cerebral circulation. Her arms, too, are sometimes benumbed ; and the fingers dead- 
ened, so that she cannot grasp anything firmly. Her manner is hurried; and at 
times there are movements about her like the first indications of chorea. Several of 
the teeth have lately become carious. Her legs swell ; appetite fickle ; pupils dilated. 
7'here is a general pallid appearance, although this has been somewhat improved by 
a steel mixture, and occasional aperients, which she has taken as an out-patient. 
Bowels well open. 

Ferri Iodidi gr. xvi. Tinct. Calumb. gi. Aq. ^vij. ft. Mist. Cap. cochl. 
ij. magn. ter die. 

May 16. Feels much better, looks more lively, and her appearance has improved. 
Complains of dyspnoea, on any unusual exertion. Bowels open; pulse small, quick, 
and vibrating. Has continued the iron mixture; was enjoined to keep the surface 
warm by sufficient clothing, and was ordered to take exercise daily. Under this plan, 
her strength increased, she became stouter and of a more natural colour. She suffered 
headaches occasionally, which an aperient usually relieved ; and on June the 4th, the 
following report was entered. 

" The catamenia appeared two days ago, the discharge lasting only twenty-four 
hours. She has felt great relief from this circumstance ; her general health has 
greatly improved ; pulse 80; bowels well opened daily ; tongue clean." 

July 4. Presented cured. 



Case 4. 

reported by mr. foote. 

Charlotte , aged 26, an unmarried woman, with dark hair and eyes and 

chlorotic aspect. The menstrual function for the last seven years has been irregu- 
larly performed, there having been suspension for five or six months, and always a 
scanty flow. Her present symptoms are, palpitation, dyspnoea, cough, pains in the 
chest and loins and between the shoulders. Her legs are cedematous ; she has no 
appetite ; her pulse is 80, and soft ; tongue clean ; bowels confined. 

Cap. Jul. Amnion, cum Magn. et Tinct. Card. Co. ^i. ter die. 
Beef-tea. Arrow-root. 

June 20. Appetite slightly improved ; still there is pain in loins and back. 

Ferri Iodidi gr. xviij. Tinct. Calumb. %i. Aq. ^vij. ft. Mist. Cap. coch. 
ij. mag. ter die. 

Allowed one pint of porter daily ; and of wine, an ounce and a half. 
July 5. She has been improving considerably under the treatment, and makes but 
little complaint. Her bowels are very confined. 



36 CHLOROSIS. 

Pil. Rhei. Co. gr. x. o. n. s. , 

Tinct. Castor. Sp. Lavand. Co. aa §i; Ammon. Subcarb. 9i. Aq. Un- 
nam. gvij. ft. Mist. Cap. cochl. ij. magna ter quotidie. 
26. Face losing its chlorotic appearance ; better in all respects. 

Inf. Gentian. Co. Inf. Sennse aa Jvi. bis die sumend. 
Aug. 4. The menstrual discharge, which appeared on the 1st, has lasted three 
days; complains now only of headache. 

12. She was discharged, with her health and countenance very much improved. 
Sept. 6. Returns to-day, to say that she is well. The catamenia have again ap- 
peared, in proper quantity, and for four or five days. Her cough, dyspnoea, and pal- 
pitation have not returned at all since the last period. 

These few cases, selected from many similar ones, are sufficiently 
numerous to insure a trial for the plan of treatment pointed out, and 
to demonstrate the importance of early and unremitted medical care. 
Neglect, in these instances, would probably have insured aggravation 
and severity; and instead of a cure easily accomplished, there would 
have been protraction, difficulty, and danger. It is worthy of remark, 
that the iron will not suit every individual; and although it has a more 
direct and salutary effect, where the uterine functions are torpid, than 
any other known remedy, yet the quinine must occasionally be substi- 
tuted. I cannot forbear especially to urge the daily use of mild ale or 
porter; as, independently of its agreeable properties as a beverage, it 
greatly assists in the restoration of flesh and strength. If these can- 
not be taken, port, sherry, or madeira wines, with hot water and a 
little spice, will advantageously excite the stomach, and promote di- 
gestion. 

The temperature of the body is often supported with difficulty in 
chlorosis; and as cold induces congestion, warm clothing and exercise 
are important adjuvant measures. The circulation of delicate girls 
is feeble and lymphatic; their stomach and bowels are soon deranged; 
and by such causes the uterine functions are interrupted and im- 
paired. 

CASES OF INVETERATE AND CONFIRMED CHLOROSIS. 

I shall insert only two such — because it is easy, after what has 
been already advanced, to imagine an aggravated form of the malady. 
Still it would not be right altogether to omit its illustration by ex- 
amples. 

Case 5. 

Miss B , set. 27, March, 1833, began to menstruate at 15, and till within the 

last three years has enjoyed good health. Since this period she has lived in town, 
and the catamenia have been gradually diminishing in quantity and in colour, till 
now the discharge scarcely lasts more than a few hours, and has lost all sanguineous 
tinge. The pulse is 108 to 120, irritable and easily compressed ; the breathing is 
quick and short, on the slightest exertion ; and the heart palpitates often and violently. 
Her depression is extreme, and she entirely desponds as to her recovery. 

There is no acute neuralgic pain of the head, but she suffers much from vertigo 
and loss of memory. Her aspect is a dirty, almost green yellow, very much beyond 



CHLOROSIS. 37 

the pallor of incipient chlorosis ; the bowels are generally constipated, but occasionally- 
much purged, the motions being highly offensive and dark. There is a fetid odour 
about the breath ; frequent nausea, and sometimes vomiting; the cellular and mus- 
cular tissues are flabby, and the alarm of her friends has been especially excited by 
her progressive emaciation, and her icterode hue ; the tongue, lining membrane of 
the mouth and lips, are of unhealthy paleness ; there is a dark mark under the eyes, 
and at the angles of the mouth ; the nails are chipped and dark ; and the skin is dry. 
In addition to these symptoms she has frequent hacking cough; and although it is 
thought to indicate approaching phthisis, it evidently depends very much on nervous 
excitement; emotion or hurry invariably produces it, and there is no expectoration, 
pain in the side, or morning perspiration : on the whole there can be no doubt that 
this is a severe and aggravated case of chlorosis, as yet a functional disease, and one 
which will probably yield to persevering and careful treatment. 

She was ordered the following : — 

R. Ferri Iodidi gr. xv. Tinct. Card. C. %]. Aquse destillatse ^vij.M. ft. 

Mist. 
Sumat Coch. i. magnum ter quotidie. 

R. Pil. Rhei. C. Extr. Colocynth. C. aa gss. Hydr. Chloridi gr. v. 01. 
Cassias gtt. xii. M. ft. Pilulas xiv. Sumat ij. vel iij. alternis noctibus. 

Chocolate or coffee and broiled bacon for breakfast ; roast or broiled meats 
for dinner, with mild malt liquor, especially ale ; weak coffee or choco- 
late in the afternoon ; and a sandwich, with a small quantity of ale, for 
supper. 

March 14. Is still feeble; although in several respects better; has less cough; 
breathing less quick ; nor does the heart palpitate so violently. Has more appetite; 
the bowels are in a healthier state ; and there is less leucorrhoea. 

She is strictly to continue the same plan. 

April 1. Is steadily improving ; there has been a very slight menstruation. — Per- 
gat. 

April 14. Has had the catamenia for two days and a half; the secretion of good 
colour and large in amount; palpitation and pain of side much less; appetite im- 
proves very slowly ; aspect clearer. Thinks the iron produces headache; pulse 100. 

Omitte. Mist, cum Ferr. Iodid. Cont. Pilulse. 

R. Infus. Rosse C. ^vij. Tinct. Humuli, Tinct. Card. C. aa ^iv. Q,uininse 
Sulph. 9i. Acid. Sulph. dil. rr\,x. 

M. ft. Mist. Take one tablespoonful three times a-day. 

May 26. The catamenia have returned twice since her last visit; and the secre- 
tion has been altogether healthy. Is still far from strong; but the cough and all the 
distressing symptoms are so greatly improved as to leave no doubt of ultimate reco- 
very ; she is about to visit Tunbridge Wells. I saw this patient once more in the 
latter part of the summer, and she was entirely restored. 

The next case is one of aggravated chlorosis, complicated with 
menorrhagia and leucorrhoea. 



Case 6. 

Mrs B , aet. 38, is the mother of six children, the youngest now, July, 1837, 

four years old ; she has been formerly weakened by over-lactation, and by several bad 
miscarriages. Has been menorrhagic for the last three years, the discharge not only 
being profuse and clotted, but lasting for eight or nine days, with leucorrhoea in the 
intervals. A humid atmosphere has aggravated the disease; the aspect is highly 
chlorotic ; the hue of the skin dirty white; and the dark marks about the eyes and 
angles of the mouth and alae of the nose are especially apparent. It is scarcely ne- 
cessary to say more than that every symptom of the disease exists in aggravated 



38 



CHLOROSIS. 



form, especially vertigo. She dare not, sometimes for a day or two, walk across the 
room ; her body seems to have been almost drained of its blood ; and what remains, 
iudaino- from what is lost in epistaxis, is very watery and attenuated. 

Her^reat fear is that she shall become entirely dropsical, as her lower limbs are 
anasarcas and the arms (edematous. She is hysterical and nervous, almost to in- 
sanity. 

I need not detain the reader by the daily and weekly details ; suffice 

it to say, that a year elapsed before the disease was cured. A variety 

of'palliative and adjuvant remedies were employed ; but the great 

benefit was derived from iron, ergot, and camphor. 

The form of pill, most frequently exhibited, I annex. 

B. Ferri Sulph. vel ammoniat. gr. ij. Camphorse gr. iss. Cons. Ros. 

q. s. ft. pilule. Take one pill twice or three times a-day, or 
R. Ferri Sulph. 9i. Secalis Cornut. (in pulvere) 3ij. Syr. Simp. qs. ft. 
piluke xii. Take one, or two pills, twice or three times daily. 

It must be borne in mind, that the ergot is a remedy of variable 
power, although, in the cases fit for its use, it more frequently fails 
from not being fresh, and from having been long in a powdered state 
and exposed to the light, in a white bottle, than from a want of bene- 
ficial activity in the genuine drug. 

The menorrhagic and leucorrhceal form of the malady is rare in 
early life. It generally occurs in women who have borne children, 
who have worked hard, and who have lived irregularly, and on 
scanty and poor food. I have seen several cases of this form of the 
disease in the wards at Guy's ; and it is worthy of observation, that 
iron succeeds almost invariably in their cure. Perhaps this may 
prove that they are chlorotic maladies. Were they merely cases of 
loss of blood and simple anaemia, nutritive diet and a restraint of the 
hemorrhage would cure them ; but I am convinced they are more than 
this. The indications of chlorosis are really present, and the remedies 
for chlorosis, especially iron, will be required. 



CHLOROSIS COMPLICATED WITH VICARIOUS DISCHARGES OF BLOOD, 
AND DISORDER OF THE STOMACH AND BOWELS. 



Case 7. 

i 

REPORTED BY DR. JOSEPH RIDGE. 

Aug. 9, 1836. Eliza , aged 16, a delicate, chlorotic girl, with pale cheeks 

and exsanguine prolabia ; has always lived in London, and has enjoyed tolerably good 
health 

She has been engaged for the last four years in a sedentary occupation (waistcoat- 
making) ; and has rarely quitted the house, sometimes not for weeks together. The 
catamenia appeared first a year ago, continuing for three days, but were of light co- 
lour: they observed the natural period for five or six months ; but on each successive 
recurrence were more scanty and serous, with lumbar and pelvic pains, and great 
lassitude. For the last twelve weeks, the function has been entirely suspended ; and 
she has suffered, for some time, from dyspepsia, constipation of the bowels, and in- 



CHLOROSIS. 39 

tense headaches. Nine weeks ago, she had a severe attack of hsematemesis, which 
was preceded and attended by considerable pain over the stomach, and sickness after 
eating. It continued for four days; and, according to her own account, she must 
have vomited altogether several pints of blood. There has been occasional epistaxis 
since; and once or twice, a slighter return of hemorrhage from the stomach. She 
at present complains of flatulence ; pain in the left side ; of dyspnoea ; disturbed action 
of the heart upon exertion; and pain in the occiput. The tongue is pale, moist, and 
flabby; pulse quick, silky, and irritable. 

Sumat Pil. Colocynth. cum Calomel, gr. x. bis in hebdomada, hora somni. 
Mist, cum Ferri Sulphat. ^i. ter quotidie. 

Liq. Ammon. pur. 3iss. Lactis tepid. Oct. i. pro Injectione, quotidie 
utend. — Meat diet, and a pint of porter daily. 

Aug. 20. Is relieved from many of the symptoms: slight epistaxis yesterday: 
bowels well open. — Pergat. 

24. Complains of fulness and pain of the stomach and head ; her aspect is less 
anarniated. 

27. Considers herself much improved : appetite good : pulse stronger : complains 
only of headache: she was ordered to take air and exercise, in the square. 

30. Makes no complaint. Some colour is returning to her cheeks; and though the 
catamenia have not yet again appeared, her general health is so rapidly improving, 
that she is allowed to become an out-patient. 

Sept. 8. Has menstruated fully and without pain, and is rapidly recovering her 
health. 



Case 8. 
reported by dr. joseph ridge. 

Eliza , aged 19 ; a girl of light hair ; of pale, waxy, and chlorotic aspect ; 

and under the middle stature : admitted as a patient of Dr. Ashwell, Jan. 7, 1836. 

She was born in London, has been occupied as a domestic servant; and till within 
the last twelve months has enjoyed good health. Menstruation commenced at the 
age of 18; and was perfectly natural till the commencement of her illness; at 
which time, the function was suddenly suppressed, the suspension still continuing. 
Her general health has been gradually giving way, and there has been progressive 
emaciation. 

Vicarious discharge first occurred during: the last week; and on three successive 
days she vomited about half a pint of dark-coloured and clotted blood. Her present 
symptoms are, pain in the head, accompanied, on assuming the erect posture, by vio- 
lent throbbing, giddiness, swimming of the sight and singing in the ears. There is 
palpitation of the heart, increased on exertion ; inability to lie on the leftside ; globus 
hystericus; dyspnoea with slight cough, but without expectoration; constant pain of 
the right side ; loss of appetite ; occasional tumefaction of the abdomen ; constipation 
of the bowels ; and at intervals, abdominal pain and tenderness. The tongue is clean, 
but pale and relaxed : pulse 90, compressible, yet jerking. 

Sumat Pil. Colocynth. cum Calomel, gr. x. ter in septimana. 
Mist. cum. Ferri Iodido more solito prseparat, coch. li. majora ter quo- 
tidie. 
Utatur Inject, cum Liq. Ammon. pur. et Lacte quotidie. 
Diet, Beef-tea, and Arrow-root. 

Jan. 12. Complains of pains in the sternum, in the region of the heart, and of 
throbbing pains in the head : sleeplessness. Skin cool 

Pergat. 

App. Cucurbitulse sine ferro nucha?. 

18. Feels better, though the head is still painful and dizzy. 
To be electrified. 



40 CHLOROSIS. 

i 
23. Severe pain in the left side, probably hysterical : head is very painful, and 
throbs violently : bowels open : tongue clean. 

Omitte .Mist, cum Ferro. Sumat Decoct. Aloes C. ^iss. quoque primo 
mane. 
28. Suffers still from dyspnoea, and neuralgic pains in the side: headache: ab- 
domen tumid : bowels open. — Pergat. 

Feb. 4. There has been considerable improvement: she has been freer from pain, 
and is active about the ward; bowels are well relieved. 

6. Continues to improve: is much less subject to dyspnoea and palpitation: the 
pains in the head and side are relieved. There has been no appearance of the men- 
strual secretion. 

9. Has a return of the former symptoms, though not in so aggravated a form. 
Bowels open. 

Mist. Ferri c. ^i. ter die. — Pergat. 
15. The pain in the side is increased ; otherwise she continues the same. 
Emplast. Opii part. dol. 

22. She now complains of a load at the stomach, after taking food : and for the 
last day or two she has vomited about an hour after dinner. Tongue clean : pulse 
feeble. 

27. Since the last report, she has been better until yesterday afternoon, when after 
dinner, she retched violently, and brought up a small quantity of dark-coloured blood, 
after which the dyspnoea and pain in the chest returned. Pulse 80, soft, but some- 
what sharper. 

March 2. The oppression at the chest returned again last evening ; and this morn- 
ing she was seized with another attack of haematemesis, and vomited half a pint of 
dark-coloured blood. Bowels open: pulse 98, and feeble. 

Cont. Medicament. 

At her own request, she was made an out-patient : and under a similar course of 
treatment, in country air, the vicarious hemorrhage was subdued ; she returned again 
to the iodide of iron, and after six weeks the catamenia appeared. 1 have seen this 
patient several times since; and, by purgatives, iron, and exercise, the bowels, and 
the uterine functions, are preserved in a healthy active condition. 



Case 9. 

reported by mr. henry oldham. 

Eliza H , aged 24, a woman of moderate stature, dark hair, fair complexion, 

and spare habit, was admitted July 4, 1835, under Dr. Ashwell. She has been married 
nine months, without pregnancy, and is employed in general household work. She 
began to menstruate at 15 years of age, since which time she has had occasional attacks 
of amenorrhcea. These never extended over many periods; but the discharge was 
usually restored by taking aloes, with new-laid eggs. She has been in delicate health 
for four or five years; principally complaining of a bad cough with expectoration, 
occasionally accompanied by pains about the epigastric region. For this she has 
been frequently blistered and leeched. For the last half-year, at every monthly pe- 
riod, she has vomited a quantity of dark-coloured grumous blood, and the catamenia 
have proportionally diminished in their amount. These attacks of haematemesis 
once or twice supervened on coughing; but usually they were the result of vomiting. 
She has latterly abstained from intercourse, as it produced intense pain in the vagina 
and hypogastric regions. 

She looks pale and wan ; complains of considerable headache and lumbar uneasi- 
ness : she is weak, and unable to perform her usual duties. There has been profuse 
leucorrhceal discharge for seven or eight months, pain in micturition, and a tenesmic 
effort to evacuate the contents of the bladder. The skin is moist; but has lost its re- 
siliency, so that, when pinched between the fingers, it is slow in regaining its natural 
position. Tongue flabby, indented at the edges, and rather foul. Bowels naturally 



CHLOROSIS. 41 

costive. The mamma* are very tender, and there is occasional nausea. On exami- 
nation, the uterus was found of its natural size, and the os and cervix of their nor- 
mal form and dimensions; they were, however, tender to the touch. Abdomen 
tumid. 

Col. cum Cal. gr. xv. statim ; et repet. alt. noctibus.— -Sumat Inf. Rosse 
cum Mag. Sulpli. gi. bis quotidie. 

July 8. The general uneasiness was relieved by the free action of the purgatives. 
The headache has been intense, and increased when in the recumbent posture. She 
sleeps heavily ; and being continually disturbed by frightful dreams, she rises unre- 
freshed. She complains of a sharp pain, on pressure, beneath the margin of the 
lower ribs on the right side. Leucorrhceal discharge profuse: pulse 100. °The pain 
in the left mamma is severe; the left nympha is elongated, and a superficial ulcer is 
seen on its inner surface. Heart pulsates forcibly. 

Ferri Iodidi gr. xvi. Tinct. Calumb. Si. Aq. destillat. |vij. Cochl. ij. 

magna ter die. 
Pil. Rhei c. gr. x. p. r. n. 
Liq. Amnion, gi. Lactis Oct. i. flat Injectio, omni nocte utenda. Hiru- 

dines vi. mamma? sinist. applicand. 

10. She feels better. The headache and pains in the mamma have decreased. 
Bowels open; pulse 90. 

Rep. Medicamenta. 

13. There is heavy dull pain in the head; aggravated on lying down, and pre- 
venting its free movements. The pain in the loins occurs in paroxysms; and is so 
severe as to occasion sudden and spasmodic starts, like those produced by an electric 
shock. Pulse 8G, soft and regular. The leucorrhceal discharge is lessened ; the os 
is still tender. The ulceration on the nympha is healed. Bowels open : countenance 
and general surface more healthy. 

15. The white discharge has been examined, and is found to be mucus. This is 
the period for the return of the catamenia, and the usual time for the re-appearance 
of the haematemesis. She has expectorated some gelatinous mucus, but no blood. 
Bowels open. Pulse quiet: lumbar pain diminished. 
Repetantur Medicament. 

20. The paroxysms of lumbar pain have entirely ceased, and she looks much 
more healthy. The catamenia have not appeared, and there has been no premoni- 
tory symptom of the haematemesis. Headache entirely relieved. Skin moist ;. bowels 
open. 

Omittant Inject, et Mist.— Capiat Ferri Carb. 3i. ter die. 
Electric sparks to be passed through the loins. 

24. The electricity has been four times repeated ; and was to-day immediately 
succeeded by considerable pain, both in the loins and thighs. The leucorrhceal dis- 
charge greatly diminished. She feels much improved. Secretions natural: appe- 
tite good. 

25. From her sensations, she expected the re-establishment of the catamenia : 
in other respects the same as yesterday. 

Rep. Medicamenta, et Scintilla? Electr. 

26. The catamenia appeared early this morning, accompanied by oreat pain in 
the loins and thiahs. .' J ° ' 

Balneum tepidum hac nocte. — Pergat. 

The discharge continued to flow until the evening of the 28th. With its cessation 
she experienced considerable relief, and quickly began to amend. The electricity 
was continued on alternate days, with the daily exhibition of the carbonate of iron. 
On the 11th of August she complained of severe pain at the scrob. cordis, sore 
throat, and headache, the effects of an imprudent exposure to cold. These were re- 
lieved by antiphlogistic measures, and soon disappeared. Under a continuation of 
the tonic plan of treatment, her strength was renovated. The surface lost its pallor, 
and the circulation was well and vigorously carried on. 



42 CHLOROSIS. 

Aug. 24. The catamenia have again appeared, accompanied by lumbar pain, and 
ovmnathptifi irritation of the mammae . , .. 

y 7nSept 2, she left the hospital, free from serious malady; and so greatly im- 
proved as to leave no doubt of her ultimate recovery. 



OBSERVATIONS. 



It will not be necessary to offer many remarks on the preceding 
group of cases. Heematemesis occurs more frequently than is supposed ; 
and in connexion with so much pain, fulness, and congestion m seve- 
ral organs, as might appear to justify active treatment. I have seen 
bleeding, purging* and lead lavishly employed; but with decided y bad 
effect In all the four cases narrated, there was anaamia, quick irri- 
table pulse, and excitement, precisely the symptoms of chlorosis, and 
such as may, without difficulty, be distinguished from similar symp- 
toms dependent on acute inflammatory disease. The transient neu- 
ralgic character of the chlorotic pains, notwithstanding their severity, 
the amenorrhea, countenance, and pulse, must lead to a correct diag- 
nosis, and to modified and local treatment. The great indication is, 
either to establish or to restore the catamenial function; and to at- 
tempt the attainment of this point, even by the empirical use of em- 
menagogues, bad as the practice may be, is less injurious than a lull 
pursuance of the antiphlogistic plan. Bloodletting can seldom be re- 
quired. On one occasion, I visited a chlorotic patient who had been bled 
from the arm for the relief of thoracic fulness and difficult respiration: 
she was partially and temporarily relieved. It was thought advisable 
to repeat the bleeding; and nothing could be more conspicuous than 
its bad effects'. Her prostration of strength was extreme; the breath- 
ing was more laborious ; and an anasarcous state of the body was 
universally apparent. Nor is it less important to reiterate the caution 
against excessive purging, especially where mercurial or drastic me- 
dicines are employed. The first object, doubtless, is to procure, by 
proper aperients, healthy and regular evacuations; but the anaemia 
of the patient must be increased by their undue exhibition— a practice 
so common, that some individuals doubt whether more harm than be- 
nefit has not accrued from their use. Let this be as it may, it is quite 
true, that the evil results of such a plan are not confined to the sto- 
mach and bowels themselves; the irritation and flatulent distention ot 
the intestines leading to aggravation of the chlorosis, and to nervous- 
ness and distressing sinking, very difficult to be borne: and yet, with 
such an increase of disorder, I have known mercury and aloes perse- 
vered in for weeks. So strong is the prejudice in favour of a "good, 

active purgation." .... , , 

Electricity, the mustard hip-bath, the ammoniacal injection, leeches 
to the vulva, moderate cupping to the loins, the various emmena- 
gogues, and occasionally a very active purgative, are the remedies pe- 
culiarly appropriate to this complication. 



CHLOROSIS. 43 



Case 10. 

chlorosis complicated with cerebral affection. 

Mary , aged 19, admitted as an out-patient under Dr. Ashwell, Nov. 10, 

1833. She began to menstruate at 13 years of age; and from that period was never 
quite well, frequently complaining of lumbar pain, headache, indigestion, &c. These 
symptoms were disregarded for three or four years, and then they became too acute 
to remain unnoticed. She is now considerably emaciated, suffers intensely from 
pain in the head, is frequently unconscious, and her intellect is greatly impaired. 
Her breathing is laborious, with frequent palpitations of the heart, and pain in the 
cardiac region. ■ If she lie down suddenly in bed, and without two extra pillows, 
her breathing is so interfered with, that she is afraid of suffocation. Her digestion 
is bad, her appetite capricious and depraved, caraway-seeds and mint being favourite 
articles of diet. Aperients are constantly given, and never without the removal of 
scybalse. Pulse 130, quick, irritable, and feeble,; pain in the side very acute: has 
not menstruated at all for the last three months, and not properly for the last year. 
Her tongue is marked by the teeth, and the lining membrane of the mouth is un- 
healthy. Her aspect is blue and leaden, and the prolabia almost bloodless. Her 
finger-nails are cracked, and her extremities are of the chlorotic hue. Urine scanty, 
and high-coloured. 

Ordered, Cordial aperients ; Leeches behind the ears ; the ^Ether-wash 
to the head ; and a pill, three times daily, composed of one grain 
each of Quinine, Camphor, and Hop ; with nutritious Animal Diet 
and mild Ale. 

Dec. 6. Somewhat better. The catamenia have not appeared. — Pergat. 

24. Less headache ; acute lumbar pain ; spasms of the lower part of the abdomen. 

Applicentur Hirud. x. labiis pudend. — Hot mustard baths. 

Jan. 6, 1834. Has menstruated for nearly four days, plentifully, and without 
pain; is, in all respects, improved. 
Pergat. 

20. Headache nearly gone; acute pain in the side, and difficulty of respiration 
less; still emaciated, and appetite impaired; bowels much constipated. 

Sumat Cal. cum Colocynth. gr. x. alternis noctibus. 

31. Bowels well cleared, and more regular; improved in appearance. 
Feb. 28. Calls to say she is quite well. 

Case 11. 

Jan. 23, 1836. Miss , aged 34; of delicate and leuco-phlegmatic appear- 
ance; menstruating irregularly and scantily, but especially for the last year; devoted 
to reading, and occasionally oppressed by anxiety, but never called upon for any 
laborious exertion. Bowels confined : pulse quick and feeble : appetite never very 
good. On the whole, up to twenty-five or perhaps thirty years of age, she was tole- 
rably healthy, and sometimes florid. The complaint for which she now seeks ad- 
vice is headache, which has existed more or less severely for six or seven years. It 
was unnoticed at first, and was accompanied by a jaundiced appearance of skin, and 
by retching; but the vomiting never removed, and scarcely palliated the pain in the 
bead. There was not much done medically for the first few years ; but her health 
became gradually more impaired ; and about twenty-four months since the pain 
assumed an intensity and constancy never'previously belonging to it: every symp- 
tom since this period has been grievously aggravated ; and the disease now absorbs 
her whole attention. In October, 1835, new symptoms arose— pain deeply seated 
in the orbit, tension of the tympanum with soreness and painful hearing throbbino- 
and beating of the head, and in a few days almost entire deafness, lasting till Decenf- 
ber ; since which time the deafness has only recurred during menstruation (which is 



44 



CHLOROSIS. 



almost amenorrhceal), alternating with a peculiar sensation of syncope, tension, and 
no?se inTe ear. Remedies have been tried, of a mercurial, depletive, and antiphlo- 
gistic kind. Pulse 110, quick and irritable. 

Good diet, principaUy animal food and ale, without wine or spirit, were 

MdeTfVon, and Colocynth as an aperient, but without Mercury, were 

exhibited; and the head was shaved, and the JEther-wash applied. 

Feb 20 Considerably improved in all respects. To use the mustard hip-bath 

before the catamenial period, and continue the same remedies _ „ orphrfl1 

March 20. Has menstruated for three days, and without pain. Her cerebral 

Sy %Tstu ^ml^ea^et^ Her intense headaches return at very dis- 
tanfTn tervals She is gaining flesh; and is able partially to resume her occupa- 
tion f teach ng. Bowels regular; urine natural; pulse 90 but feeble, an easily 
compressed. She continues the iron, and the mustard-bath, before the period. Is 
ordered to take much out-of-door exercise. Qon . m , or r 

I have not since seen this patient; but during the present month, September, 1 
have heard, from a relative who lives in the same town that there has been no re- 
lapse. The catamenial function is well performed ; and the headache and the cere- 
bral affection have entirely disappeared. 

Case 12. 

reported by mr. blackburn. 

Emily , a<?ed 17, a tall thin girl, of florid complexion, and of intelligent 

appearance, was admitted under Dr. Ashwell's care, Feb. 5, 1836. She has always 
been weakly; and for the last four or five years has been subject to chest affection, 
from which she has been free since the existence of her present malady. I wo 
years aero she had phrenitis, and has since been in imperfect health, being otten 
seized with aacrravated fits of hysteria, so that she falls and remains insensible and 
motionless for hours together. She is now deaf, and has once had otorrhcea ; but its 
presence was attributable to an accidental injury of the meatus externus. She has 
intense headache, chieflv affecting the occiput. The cephalalgia was unusually se- 
vere in Dec. 1835; and soon afterwards her right foot and hand were frequently in 
agitation. A month subsequently she lost all control over them; and since this time 
there has been ao-gravation of the pain. Ten days ago she was delirious and re- 
mained so for a few hours. Menstruation has been only once regular and natural. 
Her present symptoms are, dulness, almost imbecility of intellect ; constant and ra- 
ther acute occipital pain; frequent but not very violent agitation of the right side, 
with occasional spasms of the left; little or no affection of the face ; no difficulty ot 
articulation. Bowels open by purgative medicine; skin soft and moist. 

Pulv. Scam, cum Cal. gr. xv. statim. Ferri Subcarb. gi. quarta quaque 

hora. 
To take half a pint of porter daily, and use the flesh-brush. 

The treatment was pursued for a fortnight with advantage ; and the daily reports 
exhibit progressive amendment. The agitation is decreased, and the pain in the 
head diminished. 

Zinci Sulph. gr. ij. ter die. — Balneum pluviale omni aurora. 

Feb. 22. The agitation is much less ; and she has recovered considerable power 
of the left hand, but not so much of the leg. Bowels open ; tongue clean. 

25. The agitation has somewhat increased, and she complains of pain in the affect- 
ed arm and leg. 

Augeatur dosis Zinci Sulph. ad gr. iv. ter die. 

She continued to improve until March 11; when the nurse reported that she had 
had a fit in the night, in which she appeared to have lost the power over her limbs, 



CHLOROSIS. 45 

and the legs were somewhat contracted ; the hands were placed over the occiput, 
where she appeared to suffer pain. She is now rather confused ; pupils dilated, 
though obedient to light. There is some involuntary movement, principally confined 
to the left side. Bowels well opened yesterday ; pulse small, and soft. 

Radatur Caput. Lotio frigida constanter applicand. Zinci Sulph. gr. iv. 
ter die. 

March 16. Had another fit this morning, but much less severe than before. Pulse 
quick; pain in the head not increased. 

22. Has had no return of the fits, and appears much improved. The involuntary 
twitchings are comparatively slight. She is more collected, and can articulate 
clearly. Bowels open; pulse quiet; still deaf; her strength is so increased, that 
this morning she was able to walk twelve or fourteen yards. 

Inf. Rosse cum Q,uin. Sulph. gr. ij. t. d. — Pil. Rhei C. gr. x. p. r. n. 

She remained in the hospital till April 21, when she was presented quite well. 
During this time she gradually regained her strength, losing all symptoms of chorea. 
The general health was confirmed ; her appetite returned ; the catamenia appeared, 
though scantily ; and her countenance assumed its natural aspect. 

Her intellect is still somewhat impaired ; but the head is free from the occipital 
pain, and there is no symptom of structural change. 

The cases narrated, illustrative of this complication, require little 
comment. They attest the aggravated severity of the cerebral affec- 
tion ; and present indications so similar to those resulting from structu- 
ral change, as fully to demonstrate the difficulty of correct diagnosis. 
Although it is very rare for organic affection of the cerebrum to ac- 
company chlorosis, it must not be forgotten, if the malady continue, 
that a complication entirely functional at the commencement may lead 
to change of structure ; and that whilst the greater number of accom- 
panying symptoms are merely functional, there may exist, in some 
one organ or viscus, organic disease. Local cupping, not general 
bloodletting ; a blister to the nape of the neck ; moderate and cordial 
aperients ; change of air ; and cheerful occupation and amusement 
of the mind in society, or active out-of-door pursuits, are means the 
most likely to restore or to establish the catamenial function. 



CASES OF CHLOROSIS COMPLICATED WITH FUNCTIONAL OR STRUC- 
TURAL DISEASE OF THE THORACIC VISCERA. ESPECIALLY OF THE 
LUNGS. 



Case 13. 
reported by the clinical clerk. 

Mary , aged 21, an unmarried woman, spare made, and of pale and ema- 
ciated appearance, was admitted into Mary's ward, under Dr. Ashwell's care. 
Dec. 3, 1835. 

She has always been delicate, and liable to inflammatory attacks : she began to 
menstruate at sixteen years of age, but the function has always been irregularly 
performed. Sometimes a suspension of five months has occurred : at others, the dis- 
charge has been suddenly checked ; and rarely has she had a full and healthy 
flow. 

On the 8th of November last the catamenia appeared, which terminated an ame- 

4 



46 



CHLOROSIS. 



norrhcea of five months' duration ; yesterday there was another attempt, which lasted 
for eio-ht or nine hours, then ceased ; and the discharge, although pale and serous, 
has this mornincT returned. She has for some time been subject to leucorrhcea. 

A bout two yelrs and a half ago she had a severe attack of thoracic inflammation, 
and was areatly weakened by its treatment; there is now much debility ; the face 
is flushed", and the surface pale and waxy ; dyspnoea and pain at the epigastrium. 
She has had coucrh and mucous expectoration for several years, from which she is 
still sufferincr Sometimes she coughs up three or four ounces of a fluid slightly 
muco-purulent, and occasionally half a pint in the four-and-twenty hours. The heart 
beats violently, and is excited on the least exertion : her appetite is impaired ; and 
the pain at the epigastrium, occurring after food, is relieved by vomiting a quantity 
of watery fluid, with a remarkably sour taste: urine limpid, and secreted in large 
quantity; pulse 72, rather full : bowels constipated. 

Colocynth. cum Cal. gr. x. statim. Infus. Rosae cum Magnes. Sulph. 
bis die. 
December 8. Feels better. The cough is less troublesome ; pain diminished ; 
appetite improved ; still headache and wakefulness. 

Hydr. cum Creta gr. v. cumPulv. Tragacanth. Comp. gr. v. omni nocte. 
Mist. Oleosa cum Manna ; et Vin. Ipecac, m xv. bis die. 
11. Is greatly improved in her feelings and general aspect. Pulse 86, regular. 
Yesterday°she ate meat without the usual pain at the scrob. cordis. Leucorrhcea 
still continues. 

Rep. Medicamenta. 
17. There is an attack of pneumonia, cough, and dyspnoea; severe crepitation at 
lower part of left lung, involving a very small portion ; expectoration not altered in 
character or quantity ; skin hot. 

Cucurbitulag Cruentae ad §x. infra mammam sinistram : postea Emp. 

Lyttse. 
Colocynth. cum Calomel, gr. xv. statim. R. Vin. Ant. Tart. mxv. Liq. 
Ammonias Acet. 3iv. Tinct. Hyoscyam. m xx. Mist. Camph. £vj. 
ft. Haust. ter die sumend. 
27. The inflammatory attack readily*yielded to the remedies, and she appears to 
Slave gained strength; complains of nausea. 

Mist. Ferri Comp. §i. bis die. 

The tonic treatment was occasionally varied, but persevered in ; and she daily im- 
proved. The pulse beat regularly, usually 80 in the minute. Bowels open. She 
can eat, and easily digest meat. 

January 5. The catamenia appeared, accompanied with less pain ; and of a more 
natural colour than formerly, lasting five days. 

The congh and expectoration daily diminished. She was able to walk about, and 
left the hospital Jan. 19, with a slight bronchitis remaining, but the general health 
almost entirely restored. 



Case 14. 

Feb. 28, 1835. Miss , aged 26, began to menstruate at 14 years of age ; 

and till within the last year and a half has enjoyed good health. Since this period 
she has lived near town, and the catamenia have been gradually diminishing in 
quantity. At first, the discharge continued for half a day, or a day less than when 
in full health. Now, the flow does not last more than a day, but is unaccompanied 
by uneasiness; there is no acute pain of the head, but she is frequently giddy ; her 
digestion has been interfered with, and her appetite greatly impaired ; thirst is 
■sometimes distressing : the thoracic symptoms are, however, the most pressing; as 
her breathing is shorf, hurried, and laborious, and she has frequent hacking cough. 

Still, these thoracic symptoms precisely resemble those sometimes produced by 
chlorosis complicated with hysteria. The cough is excited by any mental emotion ; 
and loss of voice and sudden difficulty of respiration are often induced by the same 



CHLOROSIS. 47 

cause. Palpitation is of frequent occurrence. There is no expectoration of phlegm, 
but frequent water-brash: the bowels are constipated : the pulse is quick and irrita- 
ble. The aspect icterode : the tongue and lining- membrane of the mouth are un- 
healthy; and there is the dark mark under the eye; the conjunctiva preserves nearly 
its healthy and natural colour; the nails are chipped and dark; and the fingers par- 
take of the general jaundiced hue. 

Ferri Iodidi gr. xvj. Tinct. Calumbse gi. Aq. destill. gvij. ft. Mist. 

Sumat coch. magn. i. ter die. 
Pil. Rhei Co. gij, Ol. Cassias gtt. xij. M. ft. Pil. xxiv. Sumat ij. vel iij. 

alt. noctibus. 

Aprils. Has had the catamenia for two days and a half,, and is more relieved 
by the flow than formerly. Palpitation less ; pain in side diminishing; more strength ; 
appetite not much improved. 

Bacon with chocolate for breakfast; roast beef and mutton, with mild ale, for din- 
ner; weak chocolate for tea; and a sandwich, with a little mild ale, for supper: 
these were the directions given Feb. 28: the result was as described above. She 
was ordered to continue the same diet. 

May 16. Bowels irregular and confined ; less cough ; pulse 100, fuller and softer ; 
the pallor continues, and the debility is considerable. Catamenia appeared at the 
usual time, but continued only for a day. 

Cont. Remedia. 

To use for a week, previously to the period, the strong mustard hip- 
bath, every night. 
Sumat Decoct. Aloes C. |ij. cum Pulv. Jalape gr. x. alternis matutinis. 
June 20. Has menstruated fully, and without pain; the hysteria has nearly 
ceased. Circumstances of a painful nature, relative to an engagement which she 
had formed, were unexpectedly removed ; and cheerfulness and vivacity have suc- 
ceeded to gloom and anxiety. 
Per gat. 
It is unnecessary to say more about this patient, than that by a sedulous prosecu- 
tion of the remedial measures, she entirely recovered, is now married, and the mother 
of two children. 



Case 15. 

CHLOROSIS COMPLICATED WITH PHTHISIS. 

Miss , aged 15, a young lady of dark complexion, intelligent countenance, 

and of great delicacy, was attacked, at the age of 13. with hooping-cough. The pa- 
roxysms were frequent and violent; and, notwithstanding treatmenfand change of air, 
the disease lasted some months, with little or no diminution of severity. At first 
it was unaccompanied by expectoration ; but shortly a mucous phlegm was thrown 
up. Her strength decreased; her appetite was capricious; and it was feared that 
the lungs would become phthisically diseased. She was sedulously watched ; and 
her exercise, diet, and clothing were carefully regulated. Before she attained her 
14th year, the cough had lost its peculiar character, and appeared to pass into chronic 
bronchitis. The general emaciated state of the body, with the pallor and conco- 
mitant symptoms, clearly indicated chlorosis; yet it was hoped that the establish- 
ment of puberty and menstruation might lead to a restoration of health. For a few 
months, remedies to improve the constitutional power, and induce the desired change, 
tvere ineffectually employed. Her countenance became more chlorotic; the lips and 
mucous lining of the mouth more pallid and unhealthy; and the anterior wall of 
the thorax seemed* daily to approximate more closely towards the spine; there was 
not the slightest enlargement of the mammas; nor did it appear at all probable that 
puberty or menstruation would be developed. The expectoration changed its cha- 
racter, and instead of mucus, large quantities of dark-coloured pus were couched 
up, so offensively fetid as to require immediate removal from the apartment. Every 
indication was decidedly phthisical; there was hectic fiush and quick pulse in the 
evening, and exhausting perspiration in the morning; the appetite was, at times, 



48 



CHLOROSIS. 



morbidly oreat; while at other times scarcely anything was eaten. Her strength 
"pdly Lied Pectoriloquy, gurgling cough, and cavernous l^^XZrle 
rally detected by the stethoscope; and before she reached her fifteenth year, she 
sank from phthisis complicated with chlorosis. 



Case 16. 



April 1, 1838. Miss B., at. 19, of light complexion, delicate from nfancy, and If e 
quently suffering from amenorrhea, was exposed, in September, 1837 to a co d 
51 atmosphere. The result has been entire suppression of menstrual on, with its 
accompany n P a Conveniences, and severe cough. The aspect is entirely chloroic, 
"hTskin beina dirty-white, the conjunctivae, gums, and lining membrane of the mouth 
are bloodless? nor is there one indication of the malady absent. 

The expectoration, which is occasionally purulent, the pain in the left side the 
morning perspiration, and the emaciation, point very clearly to phthisis lhere is 
Sso considerable leucorrhoea. The progress of this case has been instructi e at 
first the amenorrhea did not attract attention, because it was unattended by impor- 
tant indisposition. But, in December, 1837, some more serious .^P^ 8 ^ow«d 
themselves; the chlorosis was fully established, cough, and quick pulse, with the 
icteTode hue and gradual emaciation, alarmed her medical attendants, who had care- 
fully watched and treated her. Since this period, it is unnecessary to detail the 
coarse of the disease ; but it is sufficient to add, that menstruation was never ■ resto ed 
that tubercular cavities formed in the substance of the lung, and destroyed the patient 



in October, 1838. 



Many similar examples I could furnish, scarcely a year passing 
without my seeing several such melancholy cases. I forbear ottering 
many remarks on the treatment of this most fatal complication, having 
already insisted upon the absolute necessity of continued vigilance and 
care. I may, however, suggest the importance of early and entire 
change of air. A sea voyage, a milder climate, frequent travelling, 
and cheerful society, offer the best prospect of creating or renewing 
vigour of system, and establishing a healthy condition of the pulmo- 



nary organs. c 

I have purposely avoided the discussion of the stethoscopic signs ot 
phthisis, not to dissuade the practitioner from the careful examination 
of the chest, but because I am fearful of his attaching too much im- 
portance to the absence of physical evidence of this disease. His ap- 
prehensions should be excited by the peculiar condition of the patients 
already described— a condition favourable to the deposition of tuber- 
cular matter in the lungs. To obviate the probable consequences of 
this condition will require the utmost forethought. If, however, he 
wait till these consequences have ensued, or, in other words, till aus- 
cultation affords proof that organic change is actually commencing, all 
his care and all his skill will be unavailing. 



• 



CHAPTER II. 
OF AxME NORRHCEA. 

Definition. — The absence of Menstruation. 
- There are two principal forms of the disease. 

Firsts The Amenorrhea of Retention, where, at the appropriate age, 
menstruation is absent, including three varieties. 

a. Amenorrhea, dependent on congenital deficiency, malformation 
or structural disease of the genital organs. 

b. Amenorrhea, where, independently of deficiency or malforma- 
tion, there is either a slow and partial development, or an entire ab- 
sence of puberty. 

c. Amenorrhea, after puberty is fully established. 

Second, The Amenorrhcea of Suppression, where menstruation, having 
existed perhaps for a length of time, has, independently of pregnancy 
or lactation, become suppressed, including two varieties. 

a. Recent and acute suppression. 

b. Chronic suppression. 

a. Amenorrhea, dependent on Congenital Deficiency, Malformation 
or structural disease of the Organs of Generation. 

History, Pathology, and Diagnosis. — These are happily rare cases, 
and the cure, under the most favourable circumstances, is hazardous 
and difficult, and sometimes impossible. It is now almost universally 
acknowledged, that menstruation, as well as conception, is dependent 
on the existence and influence of the ovaries. If, therefore, the absence 
of the function is connected with the absence of these organs, the dis- 
ease is irremediable. Nor will the chances of a cure be augmented, if 
both ovaries have become structurally diseased. So long as one of them, 
or even a portion of one of them, is sound, menstruation may be perform- 
ed ; but if there be entire disorganization, complete amenorrhea will be 
the result. These opinions receive additional confirmation, from the 
development of the ovaries not occurring till the age of puberty, from 
the diminution of their size, when the catamenial and reproductive func- 
tions cease ; and from the gradual lessening of the menstrual discharge, 
as disease of the ovaries progresses. In Mr. Pott's celebrated case of 
the removal of both ovaries, menstruation entirely disappeared, al- 
though, previously to the extirpation, puberty existed, and the function 
had been well performed. An instance of complete scirrhus of the 
ovaries, attended by a similar result, and occurring in my own prac- 
tice, will be narrated hereafter. 

The history of these cases is not encouraging; the health often suf- 
fers, and there is a proneness, either to irritability and excitement, or 



5Q AMENORRHEA. 

torpor and depression. I have now under my occasional care, a lady 
of thirty-two years of age, who has never menstruated, I believe irom 
congenital deficiency of the ovaries, and she is never quite well. Oi 
late* her health has been more seriously deranged ; she loses flesh, has 
frequent febrile attacks, a troublesome cough, pain in the side, and em- 
barrassed respiration. The probable termination of this unhappy con- 
dition is phthisis. In this instance, sexual development and feeling are 
entirely absent ; nor has there ever been leucorrhceal discharge. 

I cannot, without more qualification than my friend has appended, 
entirely concur in the following statement of Dr. Churchill m his 
very able and interesting work on the Diseases of Females. lnese 

patients," Dr. Churchill says, "have the body generally well developed 
and healthy, the circulation active and regular, the organic functions 
(save one) fully performed. But the breasts are not prominent, the 
genital characteristics and sexual propensities are not developed, the 
voice is deeper than usual, a slight beard appears on the upper lip, and 
there is a mixture of masculine with feminine peculiarities. ' lne lat- 
ter part of this statement is fully borne out, but the author has probably 
underrated the general amount of ill health in cases where the ovaries 
are wanting. Other organic deficiencies and malformations produce 

amenorrhoea. . 

There maybe no uterus, or if it exist it may be anormal m torm, 
its cervix may be wanting, or, together with the os, impervious. The 
vagina may be entirely absent, or so imperfectly formed, that it shall 
not be connected with the uterus; its sides may be adherent, solid 
growths may obstruct the continuity of its canal, or there may be an 
imperforate hymen. . 

I have seen several cases where the uterus could not be ascertained 
to exist ; although the presence of the ovaries was tolerably certain. 
One or two such will be given. Here the health was not seriously, 
and in one case, not at all deranged. The uterus did not exist, and, 
of course, healthy menstruation was absent. No mischief, therefore, 
arose from the retention of the catamenial discharge ; but it is far dif- 
ferent where there is a uterus, where menstruation is performed, but 
where the escape of the secretion is entirely prevented by malforma- 
tion. . 

Distention of the uterus, pressure on neighbouring organs^ impeding 
their functions, derangement of the general health, and periodical ef- 
forts at menstruation, occurring probably at monthly intervals, clearly 
distinguish these examples of retained menstruation from cases of ab- 
sent ovaries or uterus ; and show the absolute necessity for a most care- 
ful examination. 

Prognosis.— This must be unfavourable where there is a congenital 
deficiency or extensive organic disease of the ovaries or uterus. In 
neither condition can menstruation be established. It is not, therefore, 
probable that the usual amount of health shall be enjoyed, although it 
is quite true, excepting in structural disease, if such individuals escape 
phthisis, to which, in early life and in our climate, they are especially 
prone, they may, and often do, become vigorous and robust. 

Where the other malformations are present, the prognosis must 



AMENORRHEA. 51 

mainly rest on the nature and extent of the obstacles, on the practica- 
bility of a surgical or any other operation for their relief, on the degree 
of danger, not only in the operation itself, but to surrounding parts, and 
especially on the risk, certainly the most serious of all, of peritoneal in- 
flammation. The more distant serous membranes also, the pleura and 
pericardium, may become inflamed, as a secondary result of any ope- 
ration on the genital organs. 

If a safe passage cannot be made, then a fatal or very dangerous 
result may ensue from immense accumulation in the uterine cavity, 
inducing peritonitis. Nor, is it perhaps impossible that this organ 
shall be ruptured, and permit the escape of its contents. Such a case 
I have never seen ; nor from the acknowledged distensibility of the 
uterus, can I think it probable. It is far more likely, the accumula- 
tion being gradual, that the parietes of the organ will be slowly and 
sufficiently developed, to prevent rupture. The derangement of health 
and the mechanical inconveniences consequent on retention, will al- 
most certainly induce amenorrhoea.* 

Treatment. — Where the ovaries or uterus are wanting, the case is 
irremediable. Where an imperforate hymen, an occluded os, or a 
thin septum across the vagina, prevents the exit of the menstrual se- 
cretion, the knife, the bougie, or the finger, may accomplish a cure. 
If the cervix uteri exist, without a pervious canal, a trocar of small 
size, or a firm bougie, may form an artificial one ; but in the other and 
more serious malformations, where there is extensive obliteration of 
the vagina, or merely a rudiment of this passage, or where there is 
only a space between the urethra and rectum (vide cases), and where, 
although the uterus be present, it cannot be reached, except by explo- 
ratory incisions, in such complicated examples the safety of the pa- 
tient will generally depend on the discreet non-interference of the 
surgeon, while her cure must be looked for, from his courage and en- 
terprise. It is almost needless to remark that few men, qualified for 
such operations, are unwise enough to undertake them, without the 
sanction and assistance of able professional colleagues and friends. 

A case of M. Amussat, appended to this chapter, will illustrate 
these remarks. Among the means at the disposal of the surgeon, may 
be mentioned the formation by the knife, trocar, and bougie or sponge 
tents, of artificial canals and passages, the removal by incision, by 
caustic and ligatures of tumours and attached growths ; and where 
the uterus suffers from augmenting accumulation, so as to endanger 
its rupture, all other means failing, it may be punctured from the rec- 
tum. It is impossible, in a systematic work, to lay down precise rules 
for the treatment of such maladies. Each case must be considered 
alone ; its peculiarities must be coolly reflected on ; and, while teme- 
rity is to be condemned, enterprise, short of recklessness, where the 
danger of non-interference is so great, is deserving of praise. 

In the simpler obstructions, the operations, either by the trocar, 
knife, or bougie, are not difficult ; but it must not be forgotten, that 

* The author is a little obscure here; but his meaning undoubtedly is, that the 
derangement of the general health of the female whose menses are retained in and 
distend the uterus will finally induce amenorrhea ; and the secretion ceasing, the dis- 
tention will not increase and may even diminish from the action of absorption. — G. 



52 AMENORRHCEA. 

such patients, with whatever facility the impediment may have been 
removed, and a mere incision is often sufficient, are really exposed to 
the danger of peritoneal inflammation. When the operation has been 
successful, which it almost invariably is, in the simpler and more fre- 
quent cases, a quantity of dark, uncoagulated secretion escapes, and 
continues to drain away for several days. At length the uterus is 
emptied, and under favourable circumstances menstruation will occur 
naturally at the next, or at a more deferred period. 

Peritoneal or local inflammation, especially the former, must be 
carefully guarded against ; and where it is necessary to keep the ca- 
nal open by bougies, sponge tent or dossils of lint, the earliest approach 
of abdominal or local tenderness must be promptly treated. After 
such a warning, every expedient for preserving the aperture must be 
discontinued. ° If the inflammatory symptoms are slight, local deple- 
tion, by cupping on the loins or hypogastric region, leeches nume- 
rously applied, purgatives and narcotic fomentations or poultices, may 
suffice ; but if the pulse be full and hard, the skin hot, and the abdomen 
really tender, in a word, if there be peritoneal inflammation, nothing 
short of large and repeated general bleedings will avail as preliminary 
to these milder measures. 

b. Amenorrhea where there is either a slow and 'partial development or 

an entire absence of puberty. 

Causes.— As the age varies considerably, at which puberty is estab- 
lished, not only in different countries, but in individuals residing in 
the same country, the absence of menstruation at the usual epoch 
must not, at once, be regarded as a disease. Its delayed appearance 
may be caused by idiosyncrasy or delicacy of constitution, by a tardy 
development of the body generally, often dependent on impure air, 
confinement in factories, or close apartments, and many other similar 
causes. Or the health may be so feeble, owing to rapid, growth and 
excessive leucorrhcea, that the development of the genital system is 
necessarily delayed. We ought not, therefore, hastily to conclude 
that puberty will not be established, and still less that its non-appear- 
ance depends on congenital deficiency or disease ; every measure for 
the invigoration of the general health should be fairly and long em- 
ployed before the case is regarded as hopeless. It is very remarkable 
that Lisfranc should have met with fourteen cases of the total absence 
of menstruation, where he was unable to attribute such absence to 
physical obstacle or chronic affection of the uterus. 

Pathology. — The pathology of this form of amenorrhcea is the same 
as that of chlorosis ; let the amenorrhcea persist, and the anaemia and 
pallor of the latter disease, so indicative of attenuated and impoverished 
blood, will soon appear. I refer the reader, therefore, to the chapter 
on chlorosis, where he will find the subject fully explained. 

Progress and termination. — The majority of these cases terminate fa- 
vourably, especially if violent emmenagogue medicines,* for they ought 
not to be called remedies, are abstained from ; months and years, 
however, may elapse before the cure is completed, during which the 
confidence of the patient and her friends in medical skill will be severely 
tried. 

Exceptional instances, where there never is puberty and menstrua- 



AMENORRHEA. 53 

tion, are rare ; but they do occur. N<r are they always dependent 
on congenital deficiency and malformation — the powers of the con- 
stitution are sometimes entirely inadequate to the task of developing 
the genital system. 

Treatment. — When the ovaries are wanting, or destroyed by dis- 
ease, there is no remedy. Where only feebleness and delicacy of 
constitution delay puberty, judicious treatment will avail. I forbear 
to enter at large on the management, as I have done it so fully in the 
chapter on chlorosis. 

c. Amenorrhoea, after puberty is fully established. 

This form may occur, either in 

a. The too plethoric, although otherwise healthy and robust, or in 

b. The delicate, irritable, and hysterical. 

a. Amenorrhoea in the former class is invariably characterized by 
symptoms of congestion or active plethora, and is not so common as 
the second form of the malady. It is not often seen in crowded cities 
or large manufacturing towns, but in the country, where girls live 
more naturally, and are much in the air. It is generally curable, 
although often neglected. 

Symptoms. — Headache, tension, and weight about the brain, with a 
sensation of fulness and throbbing in the centre of the cranium, or 
about the cerebellum, a florid countenance, torpor, lassitude, pain in 
the back and loins, a full, and generally a slow pulse, although occa- 
sionally in irritable females it is rapid; irregular circulation, evidenced 
by the feet and hands being, the one hot, and the other cold, or both 
at short intervals remarkably hot and remarkably cold. The skin 
sometimes harsh and dry, and at others clammy. It is not to be sup- 
posed, if the amenorrhoea continue, that these symptoms will pass 
away, after the attempt at menstruation is over. They may do so 
for the first few periods, but subsequently they will continue, during 
the catamenial intervals, recurring with aggravation as the menstrual 
epoch again approaches. If the malady has been long neglected, or 
inefficiently treated, a cure will not soon be accomplished. The con- 
stitution sympathises so entirely, that months and perhaps years may 
elapse, before it resumes its healthy and natural actions. Some wo- 
men, however, naturally menstruate only at distant intervals ; and I 
had lately under my care a patient, who for two or three years men- 
struated only every four months ; and another, who never had the 
discharge oftener than every six months. Instances are also recorded, 
where healthy menstruation occurred only once every year, or once 
every two years. In my patients, symptoms of plethora were always 
present, and the menstruation was painful. Cupping, leeches, and 
purgatives, with narcotics, were the means employed. 

Causes. — Exclusive of organic deficiency or malformation, the most 
simple cause is uterine congestion, so active as to prevent the secre- 
tion of the menstrual fluid ; and this is most frequently induced by ex- 
posure to cold, which suddenly arrests the secretory process. Less 
intelligible causes have been adduced, such as torpor of the secreting 
uterine arteries and spasm of their extremities. In some of these ex- 
amples, the patients are indolent and sedentary, indulging in a luxu- 



54 AMENORRHEA. 

rious and stimulating diet, so% beds, warm apartments, and too much 
sleep. 

Diagnosis. — There is little difficulty, where the disease is seen early, 
in forming a decided opinion of its precise character. At first, there 
is neither anaemia nor pallor, and when subsequently present, the his- 
tory of the affection will prevent error. 

From amenorrhcea, where the menstrual fluid is retained either in 
the uterus or vagina, it may be easily distinguished. In the former 
there will be an absence of plethoric symptoms, the particular feature 
of this species ; while the increasing size of the uterus, and the me- 
chanical pressure on neighbouring organs, so characteristic of retained 
catamenia, will decide the diagnosis. I need scarcely add, that, if there 
be the slightest suspicion of pregnancy, examination per vaginam be- 
comes an imperative duty. 

Course of the disease, and Prognosis. — It is rare for plethoric ame- 
norrhcea to resist all attempts at cure. In such an event the plethora 
most commonly disappears, and the patient becomes chlorotic, or suf- 
fering no longer from repletion, months and years, or even the whole 
of the menstrual period of life may pass over, without the establish- 
ment of the function. Occasionally chorea, hysteria, epilepsy, hepatic 
and intestinal disease may occur, nor is it impossible that the patient 

* ii** 

may be destroyed by a general cachexy, tabes mesentenca, or phthisis. 
The prognosis must therefore depend on the character of the com- 
plication. 

Treatment. — This must primarily have especial reference to the ple- 
thora, abstraction of blood and purging being essential remedies. It 
will rarely be necessary to bleed generally, except there be marked 
congestion of some of the more important organs. Such, for instance, 
as the brain, the lungs, the liver, &c. ; in which case twelve, fifteen, or 
twenty ounces of blood may be promptly abstracted. Local depletion, 
by cupping on the loins or over the sacrum, leeches to the labia, inner 
surface of the thigh, the groins and os uteri, are ordinarily sufficient, 
and give decided relief where there is severe pain of the head, back, 
or loins. Active purgatives, and local depletion, so rarely advanta- 
geous in chlorosis, are beneficial. It is requisite to improve and in- 
crease the secretions of the whole canal, and to unload and stimulate 
the lower intestines. Jalap, rhubarb, colocynth and scammony with 
calomel at night, and a dose of salts and senna or infusion of rhubarb 
in the morning, answer the purpose exceedingly well. (Vide formulae.) 
These must be repeated with a frequency and a modification of the dose, 
suited to the urgency of the case. Auxiliary remedies must not be 
forgotten, such as the mustard hip-bath, at 96° or 98°, every other or 
every night, the common practice being to enjoin its use for ten or 
twelve minutes, instead of half an hour, one or even two hours, taking 
care to preserve the high temperature during the whole time. The 
bath used in this way is a powerful remedy. Nor is it less valuable 
sometimes, when the feet only are immersed, every night and morning, 
especially where the circulation is torpid and irregular, and the patient 
suffers much from cold, flushing of the face, or headache. Exercise 
and a spare diet must also be enjoined. Such patients should not 
be allowed to ride in easy carriages, which favours congestion ; nor 



AMENORRHCEA. 55 



is riding on horseback so good as a regular walk of several miles 
per diem, the length of the walk and the degree of exertion being, of 
course, proportioned to the strength. I have several times witnessed 
greater uterine fulness, and impaired circulation of the lower limbs, as 
•The result of horse exercise. I invariably, therefore, strongly recom- 
mend walking in this form of amenorrhcea. 

Animal food, malt liquor, or wine, must be sparingly taken. If they 
are freely used, under the impression that they will excite menstruation, 
further repletion must ensue. I have several times advantageously 
practised small revulsive bleedings ; four, five, or six ounces of blood 
may be drawn from the arm, at the period when menstrual effort ex- 
ists; leeches to the mamma? have not, in my observation, done good. 
The treatment, therefore, so long as plethora continues, includes occa- 
sional venesection, revulsive and small bleedings, cupping and leech- 
ing, active purging, constant and careful regulation of the bowels, a 
spare and sometimes a vegetable diet, prolonged mustard-baths, and 
walking exercise. 

The condition of the system may have been altered and improved, 
the treatment may have removed the plethora, but there is yet no men- 
struation. It may be asked, whether it be necessary in such circum- 
stances at once to employ emmenagogues? I think not. Some months 
may elapse before the uterus shall perform its proper function, but 
eventually, menstruation will most probably occur. If, however, the 
health fails, and instead of a ruddy and robust, there is a pale and wan 
countenance, and a gradually pervading debility, the amenorrhcea will 
merge into chlorosis: to prevent such a termination, emmenagogues 
may be used. But I must also observe, that if, when the plethora is 
removed, menstruation does not quickly occur, the continuance of the 
malady must not always be attributed to debility. Such an opinion 
leads to the premature and injurious exhibition of tonics and stimu- 
lants ; for although weakness is a cause of amenorrhcea it is by no 
means its only condition, since often, where debility has been entirely 
removed, menstruation has failed to be established. I shall, at the end 
of the chapter, discuss the various considerations, justifying and de- 
manding the exhibition of emmenagogues. 

b. Amenorrhcea , after puberty is fully established, in delicate, irrita- 
ble and hysterical females. — What is there to distinguish this form from 
amenorrhcea in females who, having been plethoric, are so no longer? 
I have observed that the former are generally more healthy; and after 
the removal of the plethora, they more quickly and easily menstruate; 
girls, on the contrary, naturally delicate, if menstruation does not 
quickly succeed puberty, very often suffer for months and years from 
non-performance of the secretion. 

In both forms of amenorrhcea now under consideration, viz., where 
it exists after plethora is removed, and in delicate females, it is under- 
stood that puberty is established: but even with this advantage, pre- 
suming that the amenorrhcea persists, chlorotic symptoms will ensue, 
and if emmenagogues have not been successfully used or menstruation 
has not naturally occurred, the proper definition of the malady is, ame- 
norrhcea complicated with chlorosis; and to avoid perplexing repeti- 
tions, I refer the reader to the preceding chapter of the work. 



56 AMENORRHEA. 

Second, The Amenorrhea of suppression, where menstruation having 
existed, perhaps for a length of time, has, independently of pregnancy 
or lactation, become suppressed. 

There are two varieties. * 

a. Recent and acute suppression. 

b. Chronic suppression. 

Causes and Symptoms.— -If it be somewhat difficult, in every instance, 
correctly to discriminate the complicated forms of amenorrhcea and 
chlorosis, it is easy, from the history and symptoms, accurately to dis- 
tinguish a case of suppression. Menstruation is healthily suspended 
only during pregnancy and lactation; but it must not be forgotten that 
the natural termination of the function may, from idiosyncrasy of con- 
stitution, arrive some years before the usual age. 

The two great causes of acute suppression are mental emotion and 
the application of cold. Sexual intercourse during menstruation, fever, 
either idiopathic or secondary, hemorrhage or venesection, severe 
trying or drastic and emetic medicines, iced water and confectioner's 
ices, are auxiliary and less frequent causes. The effect of cold in sud- 
denly arresting menstruation is well known; whether it be applied by 
a stream of cold and damp air, by wet feet, by drinking cold water, 
when hot, or by undried linen. Nor are we less familiar with the in- 
jurious effects on the sexual functions of joyous and painful emotions. 
Not only is the secretion of the catamenia prevented, when about to 
occur, but when menstruation is present it is often immediately checked 
by sudden terror. The same observation is true also of the secretion 
of the milk. Happily the effect of several of these causes is diminished 
by the frequency of their occurrence. The bathing women go into 
the sea, during menstruation, with perfect impunity; and the habitual 
exposure to the casualties of life necessarily diminishes their injurious 
impression. Dr. Gooch relates that a patient of his consulted him long 
after the entry of the Cossacks into Paris, for an amenorrhcea, which 
was solely produced by the alarm she then suffered. And Dr. Churchill 
states that almost all the women who are sent up to the Richmond Peni- 
tentiary, near Dublin, after having been tried at the Recorder's Court, 
labour under suppression, in consequence of the mental agitation and 
distress they have undergone. 

If it be asked how these causes operate, I reply, very differently. 
The effects being modified not only by the intensity of the cause, but 
in great measure also by the constitution of the individual. 

In a young or middle-aged woman, fleshy, of plethoric habit and 
ruddy complexion, the immediate suppression of the secretion will be 
followed by congestion, if not by inflammation. While in a woman 
delicate, thin, and spare, of sallow aspect, and highly nervous, the 
more probable consequences are irritation, attended by spasm and pa- 
roxysms of severe pain, with intervals of ease. In the former case 
there will be sensations of weight and pain in the head and loins, ten- 
sion and acute and constant pain in the region of the uterus aggra- 
vated on pressure, short breathing, a hot skin, and a full, hard, and 
rapid pulse; occasionally there will be violent hysteria, and I have 
several times observed delirium. It is scarcely necessary to add that 



AMENORRHEA. 57 

suppression, accompanied by such symptoms, is far more immediately 
dangerous than any of the other derangements of menstruation. Gooch, 
indeed, mentions an instance of suppression, where, after death, the 
uterus was found in a state of gangrene, the result of intense inflam- 
mation. 

About this form of suppression, then, there can be no doubt ; neither 
the symptoms nor the treatment are at all masked or perplexing ; it 
is much more than irritation, it is decided inflammation of the uterus. 
Apoplexy is said, by Capuron, to result from sudden suppression : this 
I have never met with, although I have seen seizures of a mixed kind, 
where there was something beyond hysteria, an approach to epilepsy. 
Partial and transient paralysis of the lower extremities has occurred 
once or twice in my practice ; and Churchill mentions that the patient 
may also be attacked by local inflammation, either of the brain, lungs, 
or intestinal canal. 

The pathology of acute suppression is clear. There is, in the marked 
cases, inflammation of the substance and of the investing and lining 
membranes of the uterus. Of course, a similar remark is true of other 
viscera, when they are inflamed during menstrual suppression. 

Diagnosis. — In plethoric and robust women the diagnosis of the ma- 
lady cannot be difficult. The history of the case removes every doubt 
as to the fact of suppression ; and the character of the symptoms is 
too decided to allow any other conviction than that the disease is in- 
flammatory. 

Treatment. — It is essential to the safety of the patient, where inflam- 
mation of the uterus, or its appendages, really exists, that general 
bleeding should at once be resorted to. If cordials be given and fomen- 
tations applied, with the view of restoring the suspended secretion, 
valuable time will be lost, and inflammation may, during the interval, 
advance rapidly to an incurable or gangrenous stage. Even were 
menstruation to be re-established, the inflammation would scarcely be 
diminished ; the disease, therefore, being so dangerous, must be treated 
as though it were quite independent of the suppression. Of course, 
the amount of blood to be abstracted must depend on the intensity of 
the inflammation, and the strength of the patient. It may be necessary 
to bleed largely, and more than once : fifteen, twenty, or twenty-five 
ounces may be abstracted, and colocynth, with calomel, must be im- 
mediately exhibited, to secure a full purgative effect ; a powerful ene- 
ma should succeed the pills. If, in a few hours after the first vene- 
section, the pain and the pulse are unimproved, more blood should be 
drawn ; if, however, there is less abdominal tenderness, and a diminu- 
tion in the number and hardness of the pulse, twenty or thirty leeches 
applied to the uterine region may suffice, without the second bleeding. 
A saline mixture with digitalis, a pill containing antimonial powder, 
opium, and calomel (vide formulae), may be administered every two 
or three hours. After these measures, auxiliary ones may be employed. 
A general or partial warm bath, at 96°, is a powerful sudorific, par- 
ticularly where the patient, being placed in an easy position, remains 
in the bath thirty or forty minutes ; fomentations of equal parts of gin 
and strong decoction of poppies, and an injection into the rectum of 



58 AMENORRHEA. 

half an ounce of barley-water and thirty minims of liquor opii sedativ. 
often produce great relief. Modifications of this treatment will be sug- 
gested by the differing degrees of severity, and consequently of danger 
appertaining to each "case. Nor must it be forgotten, that the sup- 
pression, although the cause of the malady, is unimportant, when com- 
pared with active inflammation in an organ highly vascular, and co- 
vered externally by a serous membrane. 

But suppression of menstruation occurs also, and perhaps more fre- 
quently, in delicate and spare women, who are highly nervous and 
irritable. Inflammation may, even in them, be the product of suppres- 
sion ; but in the majority of such attacks, the pain and other symp- 
toms are not inflammatory, although it is sometimes difficult to distin- 
guish the aggravated neuralgia and spasm of the different abdominal 
organs, and of the uterus and its appendages, from real inflammation. 
Still it may be done, although it requires some of that unwritten ex- 
perience, that incommunicable tact, which a man can alone acquire 
by long and accurate personal observation. The pain is rarely fixed, 
attacking first one and then another viscus, changing its locality with- 
out the use of remedies ; and, if treatment be employed, such as local 
bleeding, a mustard poultice, or a stimulant and narcotic embrocation, 
* it is remarkable how quickly the pain is transferred from the uterus to 
the head, from the head to the chest or heart, and again from these 
parts to the intestinal canal. The patient is prone, during these at- 
tacks of irritation, to fits of hysteria, and syncope. 

Treatment.— General bleeding is inadmissible, nor are leeches'usually 
advantageous: metastasis of the pain, but rarely its permanent removal, 
may be produced by their application. Active purgatives are ne- 
cessary, for the bowels are commonly loaded, and hard scybalous 
faBces long retained in the large bowels, excite and maintain painful 
irritation. A general warm bath at 96°, a warm mustard hip-bath 
or mustard pediluvia, may be advantageously employed. The follow- 
ing anti-spasmodic draught may be given every three or four hours, till 
the symptoms begin to subside : — 

R. Liq. Amnion. Acet. gij. vel iij. 

Tinct. Castorei vel Assafcetidas gss. ad gj. 

Pulv. Ipecac. C. gr. iv. vel v. 

Mist. Camph. gvij. M. ft. Haust. 

In addition, if the pain be severe, a pill, containing two or three 
grains of camphor, and two grains of antimonial powder, may be ex- 
hibited. 

Injections into the rectum sometimes produce an almost magical 
effect. Laudanum, assafcetida, and poppy syrup are employed for 
this purpose (vide formulas), and as it is necessary that they be re- 
tained for some time after their introduction, a piece of sponge or a 
napkin should be kept firmly and closely applied to the extremity of 
the bowel. . When narcotic enemata are injected, the quantity should 
not exceed two or three ounces, as more will unnecessarily dilute the 
anodyne ingredient, and, by distending the gut, induce expulsive ac- 
tion. The pain and spasm, in this form of acute suppression, are thus 
relieved, and menstruation does oftener recur during the immediate 



AMENORRHEA. 59 

period, in this, than in the N inflammatory species ; but in neither can it 
be invariably expected. If, however, the treatment has fortunately re- 
established the discharge, every precaution ought to be employed to 
prevent the exposure of so susceptible a patient to any of those causes 
which might induce a relapse. It need scarcely be remarked, that an 
•attack, either of inflammation or irritable suppression, is often the pre- 
lude to more permanent menstrual obstruction ; and if month after 
month elapses, without the performance of the secretion, chronic sup- 
pression, to be next treated of, will be the result. 
_ After a primary attack of suppression, unless any symptoms of ute- 
rine congestion remain, treatment in the interval is rarely necessary, 
but immediately previous to the subsequent periods, every measure 
should be adopted calculated to insure natural menstruation. The 
bowels should be kept free by mild laxatives ; cold should be guarded 
against ; the feet and the surface of the body generally should be kept 
warm ; mental emotion and undue physical effort should be avoided, 
and the mustard hip and foot-baths should be used on alternate nights. 
If menstruation return at the expiration of the first or second month 
after the suppression, anxiety is at end. If not, and leucorrhcea with 
other symptoms shall appear, then more active treatment must be 
adopted in the intervals, so as to prevent, if possible, chronic suppres- 
sion. 

b. Chronic suppression. 

Causes, Symptoms, and Pathology.— Chronic suppression may result 
from an acute attack, or it may gradually supervene, as the effect of 
some permanent irregularity in the secreting power of the uterus ; de- 
pendent on increasing constitutional delicacy, or decided ill health. 
It may be the issue of organic disease of the ovaries or uterus ; or the 
natural consequence of a premature cessation of the menses. It is 
not to be expected that causes so various should operate uniformly, 
nor do they. J 

In some women, the mischief having commenced in an attack of 
acute suppression, healthy menstruation cannot be restored, at least 
without difficulty and delay. A painful effort is made at monthly in- 
tervals ; but the discharge does not appear, and the amenorrhcea be- 
comes chronic and inveterate. In others the function is, for some 
time, scantily, irregularly and painfully performed; but the excreted 
fluid is pale and serous, and, after a few more months, the periodical 
mohmen having died away, chronic menstrual suppression is perma- 
nently established. There are, however, cases of healthy menstruation 
where the quantity of the secretion is so extremely small, that, but for 
the regularity of its return, it might be believed that chronic suppres- 
sion was approaching. Several examples of this kind are known to 
me. Nor does such a state greatly interfere either with the health or 
conception. In one patient, whom I have attended in numerous con- 
finements, the menstrual periods have never lasted more than a day ; 
yet she has been exempted from anything beyond the indisposition 
common to women. In another, married late in life, where the men- 
struation was equally scanty, I tried, at her suggestion, to increase the 
secretion ; but the vicarious remedies employed, such as iron, sarsapa- 



gO AMENORRHEA. 

rilla, quinine, mercury, and iodine, failed. Her marriage, however, has 
been prolific, and she has become the mother of four healthy children 
in three years. Since her last confinement the same sparing menstrua- 
tion again returned, proving that, in her case at least, the peculiarity 
was not morbid, as neither remedies, pregnancy, nor parturition, ef- 
fected any change. Dewees says of these instances, if there be no 
ill health, that infertility after marriage may often be attributed to an 
anticipation of final menstrual decline. He mentions three instances 
where the function ceased altogether before the twenty-fifth, and two 
where it terminated finally before the thirtieth year. In all, the health 
was perfect. I have now a patient, in her thirty-sixth year, who, 
having suffered from dysmenorrhcea up to thirty-one, ceased then to 
menstruate. Her health has been gradually improving ever since. 

It is not difficult to recognise the symptoms attendant on chronic sup- 
pression. Among the head symptoms, there are occasional vertigo, dif- 
fused and obstinate headaches, musese volitantes and dilated pupil, with 
involuntary twitchings of the eyelids and muscles of the face. The 
surface is irregularly coli, hot, or dry, while there is a manifest sus- 
ceptibility to the impression of cold, causing shuddering. The prevail- 
ing state of bowels is constipation, from weakened muscular power; 
and the accumulations in the bowels greatly interfere with nutrition, 
as the flabbiness of the textures and the occasionally rapid emaciation 
sufficiently prove. The urine is abundant and limpid. The thoracic 
symptoms are dyspnoea, palpitation, pains in the chest, &c. If the 
suppression continue, these symptoms may persist, or if the constitu- 
tion be equal to the task, it may, with the aid of remedies, re-establish 
natural menstruation. The health may, however, seriously fail ; and 
phthisis, organic disease of the liver or other abdominal viscera, or 
secondary dropsy, may destroy life. 

The pathology of chronic suppression, where it does not depend on 
organic disease, may be referred to torpor or congestion in the earlier 
stages, and to constitutional debility in its more advanced periods. In 
the protracted and inveterate forms of suppression, the ovaries and 
uterus, in common with other organs, suffer from defective nutrition, 
the blood having become too impoverished to excite the _ organic 
nerves, and to supply the requisite secretion to the several tissues of 
the body. 

Treatment— It is important to determine, not only the exact treat- 
ment to be adopted, but the precise period when it shall be commenced. 
It is not right, for instance, to regard every menstrual suspension as 
justifying medical interference. Many of the slighter irregularities 
arising from cold, mental emotion, and other causes, quickly subside, 
without medicine or professional management. If, therefore, the 
health does not suffer from the absence of the discharge, the case may 
be safely left to nature, excepting where there is excessive leucorrhcea, 
which so rapidly impairs the strength, that it is proper at once to at- 
tempt the removal of the suppression. 

Where the amenorrhcea originates from a congested state of the 
uterine vessels, the cure, under the treatment recommended, will in ge- 
neral be found more rapidly effected than in the other variety. Among 



AMENORRHEA. 61 

the irritable and delicate women, where the discharge has become 
gradually lessened, a series of functional disorders, the result of sym- 
pathetic derangements, have to be removed, which generally requires 
a prolonged treatment. 

It has been already remarked, that debility is not the sole cause of 
absent menstruation, and it is peculiarly necessary, in protracted sup- 
pression, before entering upon the use of stimulant remedies, clearly 
to ascertain whether there is not congestion or latent inflammation of 
the uterus and its appendages: if there be, such medicines must do 
harm. An examination of the uterus, externally and by the vagina, 
will procure the requisite information. Dewees strongly insists, that 
emmenagogues frequently fail from this cause, and adduces cases to 
show how important it is, where debility has been only presumed to 
exist, but where there really is inflammation, that depletion should 
precede the use of this class of medicines. During the first two or 
three months of suppression, when the constitution sympathises but 
little, active treatment is unnecessary. And the same remark is appli- 
cable, so long as the question of pregnancy is undecided. 

After the full exposition already given of the treatment of the dif- 
ferent forms of amenorrhea, it is scarcely necessary to say more, than 
that in chronic suppression, the treatment will principally be determined 
by the predominance of plethora or debility. In the former, depletion; 
in the latter, tonics and stimulants will be required. 

The following remarks on complicated amenorrhcea, I extract from 
my summary of obstetric cases treated at Guy's Hospital. 

The six cases of complicated amenorrhcea were very interesting. 
In one, it was associated with chorea. The patient, after protracted 
treatment, was eventually cured by sulphate of zinc, and the injection 
of liq. ammonias into the vagina. * In another, amenorrhcea was com- 
plicated with epilepsy. The medicine prescribed was ferri sulph. gr. 
i. pulv. digitalis gr. i. pulv. myrrhs gr. ij. mucil. Acaciae q. s. fiat 
pilula ter die sumenda. It is worthy of remark, that these pills were 
persevered in for three weeks, without any injurious consequences 
from the use of the digitalis ; a circumstance attributable, probably, to 
its combination with the iron. At this period, the catamenia ap- 
peared; and there has been no return of the fits. In a third case, 
hemiplegia was attendant on the amenorrhcea. This complication 
was tedious, and difficult to manage. At first, the mist, ferri c. was 
prescribed ; afterwards, the sulphate of zinc ; and an iodine liniment 
was well rubbed over the spine, night and morning. Menstruation 
was eventually established, and the patient regained the entire use of 
the side. In the fourth case, there was tsenia with the amenorrhcea. 
In addition to the other remedies, the ol. terebinth, was curatively em- 
ployed. In the fifth patient there was vicarious discharge from the 
mamma, in conjunction with amenorrhcea : the mist, ferri c. was or- 
dered, as well as the daily employment of the ammoniacal injection. 
The last patient had, in addition to the amenorrhcea, a peculiar ner- 
vous affection of one of her lower extremities, which completely sub- 
sided when the catamenial function was, by appropriate remedies, 
healthily established. 

O 



62 AMENORRHEA. 

It is right also to mention, that amenorrhea may occasionally be 
traced to hemorrhage during and after labour. In one well-marked 
case, occurring in my own practice, the patient had three times suf- 
fered amenorrhcEa from this cause, lactation not having been attempted. 
Twice pregnancy recurred, independently of the return of menstruation. 

In the chapter on chlorosis, ascites is enumerated as one of the com- 
mon results of that malady; the same observation is true of amenorrhea. 
In both, an improvement in the quality of the blood, and above all, the 
re-appearance of menstruation, are essential to the cure. 

Dr. Churchill alludes to several cases of amenorrhea, where a dis- 
tinct bruit de soufflet existed without other evidence of heart disease, 
and which disappeared spontaneously upon the re-appearance of the 

catamenia. 

Emmenagogues are remedies supposed to exert a specific power over 
the uterus in exciting menstruation ; or in other words, regarding the 
menstrual fluid as a secretion, emmenagogues are the medicines by 
which we endeavour to give to the secreting organ the state or con- 
dition on which the function depends. It is requisite, therefore, that 
these stimulating agents should be appropriate, and it would be indeed 
fortunate, if to aid the elimination of the catamenial secretion, we 
possessed a medicine, as uniformly and beneficially stimulant as mer- 
cury is in torpid states of the biliary function. Whether any medi- 
cines certainly possess this influence, is a question to which my expe- 
rience does not afford an affirmative reply. Still, although there are 
no drugs positively emmenagogue in their action, the properties of some 
in stimulating the uterus, render them important auxiliaries in the treat- 
ment of various states of diseased menstruation. 

In chlorosis, and in amenorrhea, where there is deficiency or mal- 
formation, the local emmenagogues often do harm, never any good. 
In cases too of absent menstruation, where there is either a slow and 
partial development or an entire absence of puberty, emmenagogues, 
if used at all, are improperly employed: and in chronic amenorrhea 
complicated with dropsy or phthisis, and in amenorrhea with general 
and uterine plethora, still further congestion must result from their admi- 
nistration. 

But where the uterus is inactive or entirely quiescent, puberty having 
been established, and neither plethora nor debility exist, emmenagogues 
may be advantageously tried; nor are they less valuable, where ame- 
norrhea continues, in delicate, irritable, and hysterical women, after 
tonics and cordials have failed to produce the menstrual discharge. In 
chronic suppression, emmenagogues are clearly indicated. Plethora, 
loaded bowels and fever forbid their use; spare diet, purging, local de- 
pletion, and occasionally a small bleeding from the arm, prepare the 
way for their beneficial exhibition. 

Emmenagogues are of two kinds: — 

First, Local or immediate Emmenagogues, directly applied to the ute- 
rus or the neighbouring organs. 

Second, Constitutional Emmenagogues, producing their effect through 
the medium of the system. 

Of the first class, Electricity is the only agent justly entitled to the 



AMENORRHEA. 63 

appellation ; the only power by which the uterus can be directly sti- 
mulated. It is well known, that local pain is produced whenever a 
sufficiently strong electric shock is passed through a sensitive part. 
Thus, if electricity, by shock, be directly applied to the uterus, a highly 
stimulant effect will ensue. Nor is the organ less beneficially affected, 
in some instances, by the electric sparks, or by a continued current 
being passed through it ; still it is an uncertain emmenagogue. In the 
ward at Guy's, and amongst the out-patients, it has of late been used 
with more than the usual good effects, Dr. Golding Bird having su- 
perintended its application. In some of the cases, where, after the con- 
dition of the alimentary canal had become healthy, the amenorrhcea 
continued, with slight pallor and weakness, electric shocks passed 
through the loins quickly induced menstruation. In others, its con- 
tinued repetition three or four times a- week led to a similar result; and 
instances were not wanting where a shock suddenly produced the flow. 
Electricity must, however, be cautiously employed. Where the pa- 
tient really dreads its exhibition, it may depress the nervous system, 
and still further protract the malady. Nor must it be forgotten, that 
if syncope, sickness, or diarrhoea follow its use, it ought to be discon- 
tinued. Electricity moderately applied, frequently rouses into activi- 
ty the energy of torpid organs and parts, but when used in excess it 
may altogether destroy their excitability. I rarely trust to it alone, 
nor do I employ it in cases of general plethora or local congestion. 
If pregnancy be suspected to exist, however strenuously denied by the 
patient, electricity ought not to be used ; once I ordered it, quite igno- 
rantly, where the amenorrhcea depended on concealed pregnancy ; 
and abortion occurred within an hour. 

Of Galvanism as an emmenagogue I have no experience, but it is 
mentioned favourably, although cursorily, by several authors. 

The application of leeches to the os and cervix uteri, where congestion 
exists, will frequently produce menstruation ; but it is somewhat diffi- 
cult so to employ them, and in young unmarried women it is almost 
impossible. Dr. Stroud strongly recommends the practice, and speaks 
favourably of its effects. A proper leech-glass must be used by a 
well-instructed nurse, a few days prior to the period, and repeated 
several times. 

Stimulant Injections. — These were formerly much employed, and a 
variety of irritating ingredients entered into their composition; at pre- 
sent, as a vaginal enema, the Liq. Ammonias fort, in milk, is gene- 
rally administered. 1 have often used it with success during the last 
twelve years, both in hospital and private practice (vide formulas). It 
rarely does good, if it is not attended and followed by a pungent sen- 
sation of heat, tingling, and some pain in the vagina. Its use should 
be commenced three days prior to the expected period ; and the pa- 
tient, after each injection, should apply a napkin to the vulva, so firmly 
as to cause the injected fluid to be retained for ten or fifteen minutes. 
It is not a safe remedy where there is uterine congestion. In two such 
cases dangerous inflammation of the cervix and upper part of the va- 
gina followed its use. Where, however, uterine torpor is unaccom- 
panied by congestion and acute irritation, the ammoniacal injection 



g4 AMENORRHEA. 

is often efficacious. Occasionally, like electricity, it produces men- 
struation at once, while, in some women, in common with the most 
approved remedies, it is without effect. The strong mustard hip-bath 
used twice during the day, the patient remaining in it for nearly an 
hour each time, at a temperature of 96° or 98°, is an effectual auxili- 
ary remedy. 

Stimulating fluids have been, as emmenagogues, injected into the 
uterine cavity ; and they may, perhaps, by some who have not used 
them, be yet recommended. Death, from peritoneal inflammation, 
has several times followed the practice ; and in two instances, occur- 
ring under my own eye, fatal results had nearly ensued from most alarm- 
ing attacks of this formidable malady. It has been supposed, but cer- 
tainly without due consideration, that as cold water alone or with 
sulphate of zinc may with impniuty be injected into the uterus after 
labour, so with equal impunity a similar injection may be thrown into 
the interior of the uterus in amenorrhoea ; but there is little or no ana- 
logy to support the reasoning. In the former instance, it may be 
fairly presumed that the mucous membrane is healthy, and, uterine 
contraction being secured, restraint of the bleeding will be the conse- 
quence of the remedy ; but, in menstrual suppression, there may be, 
and often is, congestion and irritation, and perhaps a diseased state of 
the tissue lining the uterine cavity — here, on the contrary, inflamma- 
tion will probably ensue. Excepting as a means of arresting hemor- 
rhage, I never now inject the uterine cavity. 

Of the emmenagogue properties of medicated bougies I have no ex- 
perience ; when used, stimulation of the lining membrane of the cervix 
is intended to be produced, with the hope that a similar action will ex- 
tend through the continuous membrane of the uterus. These, with 
the exception of the mustard and the variously medicated hip-baths, are 
all the local emmenagogues directly applied to the uterus. The mus- 
tard hip-bath, if well employed, seems at times to exercise an almost 
specific influence over the uterus. Nor is the exhibition of mustard 
by the stomach without a similar effect. I have often given eight, ten, 
and twelve grains of mustard, in camphor julep, three, four, and five 
times daily, prior to the menstrual period, with good effect, the regu- 
larity and the quantity of the secretion being beneficially affected by 
it. Dr. Rigby relates that some school girls, for sport, swallowed 
mustard spread thickly on their bread, and in all the elder girls it pro- 
duced menstruation in a few hours, although the regular period for its 
appearance had not arrived. 

It is right to allude to sexual intercourse as an emmenagogue, as 
marriage often, though by no means invariably, cures amenorrhoea. 

Stimulating injections into the rectum are much relied on by some 
practitioners, as emmenagogues, and certainly I have used with ad- 
vantage an enema — recommended by Dr. Schonlein — composed of ten 
grains of aloes, and one ounce of mucilage, twice or three times a-day. 
Leeches to the vulva, above the pubis, and at the upper and inner 
part of the thighs, are occasionally beneficial. Nor are stimulating 
embrocations, warm frictions, and the flesh-brush to the hypogastric and 
lumbar regions, to be entirely neglected. They must, however, only 
be relied on as adjuvant remedies. 



AMENORRHEA. 65 

Of the utility of Pressure on the Iliac and Femoral Arteries, as a 
remedy for amenorrhcea, I have no knowledge. Not once have I seen 
it tried. Dr. Hunter, of Beverley, first successfully employed it about 
seventy years ago. It was subsequently practised in Edinburgh, and 
Dr. Home reports that in his hands, it succeeded once in six times. It 
is not a satisfactory or rational thing to induce congestion of the ute- 
rus, if it can be accomplished, as a remedy for amenorrhcea, since it is 
admitted that the disease in question is often attributable to this very 
condition. The plan has been long discontinued. 

The Second class of emmenagogues is The Constitutional, producing 
their effect through the medium of the system. 

Mercury is our most powerful deobstruent, and deserves to be men- 
tioned first amongst the remedies of this kind. It is not to be used in 
slight cases, nor where there is extreme exhaustion, a predominant 
irritability, or a tendency to phthisical or strumous disease. But, in ob- 
stinate amenorrhcea, where other treatment has failed, where there is 
chronic inflammation or permanent congestion, and any evidence of 
incipient structural change, there is no remedy comparable to this.- In 
medicine, however, as in matters of less moment, there is a fashion : 
and in obedience to its dictates, we too often pass from one extreme 
to its opposite. The extravagant employment of mercury at one time, 
and its undeserved neglect at another, the indiscriminate praise be- 
stowed upon it by some, and its unjust abuse by others, abundantly 
verify this observation. As an alterative I have not used it success- 
fully ; but if salivation be produced and maintained, mercury often 
insures decided and permanent benefit. The inconveniences of a mer- 
curial course, protracted through three or four months, however modi- 
fied and lessened, are quite enough to induce not only great caution 
in the selection of an appropriate case, but great watchfulness of its 
effects. If the pulse becomes more rapid and less strong; if constitu- 
tional irritation and weakness daily increase ; if there be cough or di- 
arrhoea, these not having previously existed, the mercury should be at 
once discontinued. No prudent practitioner will administer it after 
such warnings. More frequently, in cases warranting its use, improved 
symptoms will follow moderate salivation. The tongue becomes clean, 
moist, and of healthy colour ; digestion improves, and there is some 
return of healthy appetite ; the complexion loses its dingy, icterode hue, 
and becomes more clear ; and the entire state is greatly improved. I 
am not aware that the form of mercury to be administered is a matter 
of much consequence. The Plummer's or the common blue pill, calo- 
mel, the gray powder, or the inunction of the mercurial ointment, may 
any of them be selected. The mercurial effect should be carried so 
far, as to produce soreness of the gums and moderate salivation ; and 
these should be kept up for twelve or sixteen weeks. 

The frequent daily use of the chlorate of soda as a gargle, will di- 
minish the inconveniences of the salivation, by removing the fcetor of 
the breath and cleansing the mouth, so as to prevent the unpleasant 
taste. Sarsaparilla is a valuable adjunct: it allays irritability and pre- 
vents emaciation. 

Iron, in its various forms and in modified doses and combinations, 



gg AMENORRHEA. 

is a most valuable emmenagogue. Its worth, in all diseases where the 
blood is impoverished and where there is general weakness, is well 
known. Its protracted administration, instead of injuring, improves the 
health ; and the blood, instead of remaining a watery and attenuated 
fluid, acquires from iron more healthy and nutrient properties. In this 
way its emmenagogue power is realized. Nor must it be overlooked, 
that iron possesses this additional value; that, as the cure of the ame- 
norrhoea is mainly dependent on the improvement which has been 
effected in the general health, so it is more likely to be permanent, 
menstruation not having been re-produced by powerful and transient 
stimuli. These remarks are pertinent to its exhibition, whether in a form 
purely medicinal or chalybeate water. The various chalybeate springs 
contain different quantities of the carbonates and sulphates ; and their 
waters are certainly most efficient when drunk on the spot. The re- 
gulations for exercise in the intervals of swallowing the water ought 
to be sedulously followed. Nor must it be forgotten, that plethora and 
constipation should be removed prior to any form of iron being exhi- 
bited ; and if, during its use, giddiness, headache, sickness, and a quick 
or full pulse should occur, the iron must be immediately discontinued. 

Of the Ergot of Bye, or Secale Cornutitm, as an emmenagogue, I 
cannot speak favourably ; nor is it on principle easy to understand how 
it should produce such an effect. As a powerful stimulant of the mus- 
cular substance in the pregnant and puerperal conditions of the uterus, 
it is, if judiciously employed, invaluable ; but the removal of uterine 
torpor, and the arrest of uterine hemorrhage, by the excitement of 
muscular action, are entirely different effects from the restoration of a 
secretion, often owing its suspension to plethora and extreme debility. 
Nevertheless, Dr. Locock, the brevity of whose papers on the diseases 
of menstruation is their only fault, speaks favourably of the deobstruent 
properties of the rye. I cannot say that I have never succeeded, when 
I have used it ; but it is necessary to be cautious, not only in selecting 
the case, but likewise the precise time when it shall be administered. 
It is most to be relied on in a somewhat relaxed and debilitated patient, 
and ought to be given, not in the intervals of menstruation, but when 
determinate efforts are being made to establish the secretion. Occasion- 
ally, at these periods and in conjunction with strong mustard hip-baths, 
it has produced the menstrual discharge. I rarely now give it, but 
never when these efforts having been unsuccessful, subside. Irritation 
and abdominal spasm are almost sure to follow its continued use. In 
one or two instances I have witnessed alarming seizures of this kind, 
where it has been long employed. The powder (see formulae), in doses 
of ten grains, two or three times daily, is probably more efficacious 
than the tincture, although the latter induces less severe uterine and 
intestinal spasm and pain. 

Iodine is occasionally a good emmenagogue ; but there is no remedy 
of this class which in my hand* has so frequently failed. In patients 
predisposed to struma, or actually suffering from scrofulous enlarge- 
ment of the glands, the iodine exerts an almost specific influence on 
nutrition, and, by improving the blood, favours secretion. Dr. Coindet 
was perhaps scarcely correct in attributing to this drug such powerful 
and certain emmenagogue properties. I have made numerous inquiries 



AMENORRHEA. 67 

about its effects, and have not discovered that others have used it more 
successfully than myself. It may be given in doses of five, eight, 
twelve, or fifteen drops, or even more, of the tincture, twice or three 
times daily, in sugared water. Or the iodine, in substance, may be 
administered, combined with the hydriodate of potass, (vide formulae). 
Caution must be observed after plethoric amenorrhea, lest a return of 
this state, accompanied by vertigo, cerebral fulness, or slight haemop- 
tysis, may succeed its use. 

Strychnine was introduced by my friend Dr. James Bardsley, of 
Manchester, in cases of suppressed menstruation. In four instances 
of amenorrhaea, occurring in delicate females, I have unsuccessfully 
used it. In two out of the four, one-fifth of a grain was taken four 
times a-day; but vertigo, and spasmodic twitching of the muscles, 
with severe headache, compelled me to lay it aside. The late Dr. 
Cholmeley, of Guy's Hospital, employed the strychnine in several cases 
of amenorrhoea, in the wards, but without any success. He began 
with the sixth of a grain three times a-day. 

Of Madder, the root of the rubia tinctorum, as an emraenagogue, I 
have little personal experience. In the commencement of my profes- 
sional studies, I witnessed its successful use ; but I believe it is now 
very rarely employed. Madder tinges the bones and the urine of a 
red colour ; it is supposed, therefore, that finding its way into the cir- 
culation, it directly influences the secretory function of the uterus. It 
is given in doses of 3SS. to gj. of the powdered root, two, three, or four 
times a-day. Dr. Home says that out of nineteen cases of amenor- 
rhoea he cured fourteen by madder. It does not quicken the pulse, or 
derange the stomachic functions, but appears to operate almost insen- 
sibly in producing the return of menstruation. 

Rue, so much praised in former times for its emmenagogue pro- 
perties, is now scarcely ever used ; nor does the evidence in its favour 
prove more than that it may be a cordial anti-spasmodic of uncertain 
efficacy. 

Savine, the juniperus sabina, is powerfully stimulant and emmena- 
gogue ; but its use is at present much restricted. Its deobstruent power 
is attributed to a volatile oil, which is similar in its properties to tur- 
pentine. Popular opinion is decidedly in its favour, and it is the me- 
dicine most commonly employed to procure criminal abortion. Dr. 
* Davis, in his elaborate work, mentions on the testimony of one of his 
pupils, who served his apprenticeship at Tonbridge, that in the neigh- 
bourhood of that town there was a remarkably fine savine tree, the 
decoction of the leaves of which was successfully used, not only to re- 
move menstrual suspension, but also to induce abortion. Where there 
is a feeble and languid circulation, savine is a suitable stimulant : but 
its use is injurious where there is plethora and irritation. The pow- 
dered leaves, and the oil of savine, are the preparations employed ; of 
the former from four to twelve grains, and of the oil from two to 
twenty drops, may be taken two or three times daily. 

Seneka root and Black Hellebore are deobstruents, but they do not 
merit more than a passing allusion. 

Nitre, by stimulating the kidneys, is a decided emmenagogue. It 



68 AMENORRHEA. 

seems to reach these latter organs, judging from its effects, without 
decomposition. I Jately gave to a patient, whose mother placed great 
confidence in this salt, one scruple three or four times daily, in a wine- 
glassful of water. It purged and produced bloody motions; but on 
the third day there was a copious flow of the catamenia after a sup- 
pression of seven months. 

The Infusion and the Tincture of Digitalis, produce their uterine 
effect through the kidneys. 

Aloes is doubtless the most efficient of the emmenagogue cathartics, 
acting on the uterus through the rectum. Even after menstruation 
has ceased, the disposition to the function often remains, but the dis- 
charge can rarely be produced by the natural efforts alone — here, if 
a drastic dose of aloes be given, the catamenia are frequently, in slight 
degree, restored. It may easily, therefore, be allowed, that a similar 
effect may occur from the continued exhibition of the medicine, during 
the epoch of menstrual life. Aloes cannot, however, be always ad- 
ministered. If there be an irritable uterus or a highly irritable stomach 
and alimentary canal, the drug cannot be borne — sickness, intestinal 
tormina, and extreme irritation of the rectum and anus, forbid its use. 
Several formulae will be given. 

Gamboge, serpentaria, wormwood, musk, myrrh, castor, valerian 
and lavender, with several others, are regarded as emmenagogues, but 
the majority of these remedies can scarcely be viewed as more than 
stimulant anti-spasmodics, and as aiding the more direct and powerful 
medicines of this class. 



CASES OF AMENORRHEA DEPENDENT ON CONGENITAL DEFICIENCY. 
MALFORMATION OR DISEASE OF THE GENITAL ORGANS. 



Case 17. 

amenorrhea gradually supervening on diseased ovaries. 

October 10th, 1838. Miss G , set. 17, a patient of Mr. Bailey, of Limehouse, 

is fair and strumous in aspect, rather thin, always delicate, but not sickly. Puberty 
was established at fifteen, and menstruation quickly supervened. In February, 1838, 
nearly nine months before the present time, a tumour about the size of a goose's- 
egg, hard, uneven on the surface, and only slightly tender to the touch, was disco- 
vered low down laterally in the right hypogastric region. Up to this period the cata- 
menia were regular in their return, although the quantity was lessened, and the colour 
light. A few weeks afterwards, in March, a similar though smaller growth appeared 
on the left side, and several of the inguinal glands were enlarged and indurated. 
Now, there are two distinct tumours, that on the right extends from the iliac fossa 
to the umbilicus, while the left iliac fossa is entirely occupied by the other and smaller 
growth. They are of stony hardness, at times painful, independently of pressure ; 
mechanically, they derange the action of the bowels and bladder, while fever and de- 
fective nutrition are rapidly destroying her strength. Appetite is impaired, and 
there is a frequent dull pain in the stomach, accompanied by acute pain and cramp 
in the backs of the thighs and legs. The sleep is much disturbed ; pulse from 100 



AMENORRHCEA. 69 

to 110, small and weak, and there are nightly paroxysms of fever; there is neither 
cough, expectoration, nor morning perspiration. 

Since June menstruation has progressively decreased, and it has been attended 
with severe pain. Six weeks ago, the second growth (both are believed to be ova- 
rian) having attained a large size, and having probably completely destroyed the 
healthy structure of the organ, a painful effort alone, without any discharge, marked 
the menstrual period. 

Eight weeks subsequently to my first visit in October, the amenorrhcea continued. 
Only^palliative treatment was recommended, the extent of the disease forbidding ac- 
tive interference. 

In February, 1839. she died, worn out by mechanical and febrile irritation, and by 
want of nutrition. Fo six months before death there was entire amenorrhcea and 
excessive leucorrliceal discharge. 

A post-mortem examination confirmed the Opinion that the uterus was perfectly 
healthy, and that the ovaries were entirely scirrhous, so much so as to have oblite- 
rated every trace of their natural organization. 

This case requires no comment. It confirms the doctrine that the 
ovaries are the efficient cause of menstruation. 



Case 18. 

AMENORRHEA WITH CONGENITAL MALFORMATION OF VAGINA AND UTERUS. 

Hannah , eet. 22, was admitted June 13th, 1832, into Dorcas Ward, Guy's 

Hospital. The following particulars are taken from the case-book and my own 

notes. 

This patient has never menstruated, but there is no abdominal enlargement. Has 
suffered severely for many months from headache, pains and tightness in the chest 
and loins. She has been plethoric, but is not so now; pulse 90; moderately full; 
tongue white, skin hot, especially at night. 

For these symptoms, subsequently attended by dyspepsia, she was bled and purged, 
and put on low diet; and on July 7th, she left the hospital cured of her indisposi- 
tion, but without having menstruated. As it was thought that malformation existed, 
this patient was, at her own request, carefully examined; and the following is the 
report: — 

Hannah is well developed as to her general womanly structure, and has 

therefore probably perfect ovaries. But the external aperture of the vagina is closed 
by a firm membrane, which, being pushed up two or three inches towards the sacrum, 
forms a shut-sac, without the slightest opening. Neither the finger nor a probe can 
detect an os or cervix uteri beyond this closed extremity ; nor does the finger in the 
rectum when pressing forwards, nor pressure downwards from above the pubes, 
cause any firm body, like the uterus, to impinge upon the finger remaining in the 
vagina. It is quite certain that there is no large- accumulation of menstrual fluid 
either in the womb or upper part of the vagina. These parts, if they exist at all, 
must be of small dimensions. No exploratory operation was recommended, as any 
attempt to lay open this shut-sac might expose the cavity of the peritoneum. If ca- 
tamenial accumulation shall hereafter render an opening expedient, the containing 
parts will be so dilated as to be felt by the finger, then the knife may probably be 
u:-ed with a prospect of success. I have, however, already said that these operations 
are scarcely ever devoid of danger. 

Here menstruation was not performed, because the secretory organ, 
the uterus, was wanting. I saw this patient again two years afterwards, 
when she had quite recovered her health, and wished to be married; 
but hesitated because she had not menstruated. I declined to give 
any advice. 



70 AMENORRHEA. 

Case 19. 

amenorrhea dependent on absent uterus and vagina. 

Dec. 20, 1836. I visited Mrs , set. 27 (a patient of Mr. New, of Mile-end). 

This lady has been married two years, and is well developed about the pelvis and 
mammae. Her general health is tolerably good, if a proneness to fever, susceptibility 
to cold, and hysteria be excepted. She has never menstruated, but in other respects 
she is sexually healthy. The genitals are singularly anormal. The mons is large, 
the labia are well formed. and the fourchette and perineum do not deviate from healthy 
conformation. There is, however, no vagina, and I think, no uterus. On passing 
the finger in the direction of the os externum, it may be carried about an inch on- 
ward between the urethra and rectum. The former canal is very capacious and dis- 
tensible, for after overcoming the contraction at its entrance, the finger may traverse 
it till it enters the bladder, the rugae of which viscus are easily felt in its empty 
state. Examination by the rectum, the finger being retained in the urethra, detects 
no body like the uterus, the two fingers approaching very closely to each other; a 
fold of membrane only being interposed between them. Intercourse is imperfectly 
accomplished, and yet not without gratification: the urethra being the recipient ca- 
nal. That there are ovaries is certain ; but 1 feel confident there is neither uterus 



nor vagina. 



Case 20. 

« 

AMENORRHEA WITH CLOSURE OF THE VAGINA. CONSEQUENT ON PROTRACTED AND 

INSTRUMENTAL LABOUR. 

In August, 1837, Mr. Maccay, and a neighbouring surgeon, requested me to visit 
Mrs. B., residing in Whitechapel ; she was twenty-one years of age, had been married 
ten months, and had been in labour nearly sixty houTS, under the care of a midwife. 
As there were not more than three inches and a quarter of space between the sacrum 
and pubis, as the internal parts were hot, tumid, and tender, and the abdomen tympa- 
nitic and extremely painful on the slightest pressure, I proposed perforation. I 
brought the head of the child through the pelvis with great difficulty even after I had 
reduced it to the smallest dimensions. There resulted, as I feared, from the long- 
continued pressure of the head on the soft parts, vaginal abscess and ulceration; and 
the subsequent cicatrization w r as accompanied by contraction. In July, 1839, not 
having seen Mrs. B. since the delivery, she cailed at my house and told me that she 
had never menstruated since the labour, but she was much weakened by constant leu- 
corrhcea. On examination, I had no difficulty in passing the finger into the vagina, 
for about two inches and a half, where it terminated in a pointed extremity. The 
closure is quite firm, and 1 cannot discover, either by the speculum or probe, the 
slightest aperture. In front, beyond this shut-sac, I cannot feel the uterus, but through 
the rectum it is easily discovered, nor is it at all enlarged. 

This patient is failing in health, is dyspeptic, emaciated, and,* since 
the labour, has become entirely devoid of sexual feeling. But I can- 
not persuade her even to think of surgical aid. It is an interesting 
case as showing the increase of constitutional morbid effect beyond 
what exists in the examples of congenital deficiency, where menstrua- 
tion was never performed ; and such an instance may be regarded as 
the connecting link between the congenital cases, and those where 
the menstrual fluid is secreted, but retained. The examples of con- 
genital deficiency are the least dangerous; cases like the one now de- 
scribed are more hazardous: and instances of secreted but retained 



AMENORRHEA. 71 

catamenia are full of risk, if the fluid cannot be evacuated, and even 
then there is abundant cause for anxiety. 



Case 21. 

AMENORRHCEA DEPENDENT ON MALFORMATION OF THE VAGINA. 

REPORTED BY MR. HENRY OLDHAM. 

Elizabeth R , aged 22, a well-developed girl, of short stature, florid com- 
plexion, and fair skin, was admitted into Guy's Hospital in February, 1836, under 
Dr. Ashwell. 

At the age of 15, she had some affection of the eyes : but with this exception, she 
enjoyed good health, until ten months ago, when she first became troubled with 
headache, vertigo, and lassitude, a sense of fulness in the hypogastric region, with 
lumbar pain, capricious appetite, pain in the side, and irregularity of the bowels, for 
which she was received into the Hospital, under Dr. Cholmeley. At this time the 
catamenia had not appeared ; and an examination was instituted, to ascertain if any 
mechanical obstacle existed. The parietes of the vagina, about two inches from the 
vulva, were found closely adherent; and fluid could be detected immediately above. 
Mr. Key divided the septum; and a large quantity of dark-coloured, viscid fluid was 
evacuated. The opening was dilated by bougies ; and she shortly left the Hospital, 
feeling well. There was but one scanty appearance of the catamenia after this 
period; but her health was not materially deranged until six weeks of the present 
time, a white mucous discharge havino- alone occurred. A recurrence of the above- 
mentioned symptoms induced her to apply to me for advice ; and, on examination, it 
was found that the two divided surfaces of the vagina had again firmly united, but 
that the catamenial fluid was accumulated in small quantity only, which was proved 
by the absence of a fluctuating tumour above the cicatrix. Finding her general 
health somewhat impaired, and the morbid sympathies with the uterus, such as sick- 
ness, headache, &c, continually present, I prescribed laxative medicines, mild tonics, 
nutritious diet, and palliative remedies, to remove urgent symptoms. The symp- 
toms became more severe, as the quantity of menstrual fluid increased ; and she was 
re-admitted into the Hospital under Dr. Ashwell. At this time, she complained of 
giddiness, headache, and tinnitus aurium, lumbar pains, with a sensation of fulness 
and bearing down, occasional dyspnoea, uncertain appetite, depression of spirits, and 
great irregularity of the bowels, sometimes being troubled with diarrhoea, followed 
by constipation. The uterus was not to be felt above the pubes; but a feeling of 
fulness, not of distinct fluctuation, was communicated to the finger, on examination. 
The same class of remedies was used, under which her general health improved ; 
and in two months' time, the tumour above the united parietes was so distinctly 
bulging, as to warrant the evacuation of the retained catamenial fluid, which was 
less in quantity than on the previous occasion. In twelve hours after the operation, 
symptoms of peritonitis were present, which were met by active measures, such as 
bleeding, both general and local, purgatives, calomel, &c. They, however, continued 
unsubdued, and she died. 

The body was conveyed to the mother's house, where an inspection was obtained. 

On opening the thorax, marked traces of recent pleuritis were universally diffused. 
The lungs, in some portions, were found adherent to the opposed pleura costalis, by 
delicate bands of imperfectly-organised fibrin, which were readily broken down. In 
other parts, layers of plastic lymph were found loosely attached to the pulmonary 
pleura, and within the pleural sac : on both sides there were three or four ounces of 
serous fluid, with some flakes of lymph floating in it. The depending parts of both 
lungs were gorged with blood and serum, which ran out from the two surfaces of a 
divided portion. The upper lobes were crepitant, but their edges were too rounded. 
The heart and large arteries were healthy. 

On opening the abdomen layers of lymph were found on the surface of the liver, 
particularly around the acute margin, and between the convolutions of the intestines. 
This lymph varied in degrees of firmness, appearing, at the under part of the liver, 



72 AMENORRHEA. 

to be converted into a tolerably well-organised band of false membrane, attaching it 
to the opposed surface of peritoneum : in other parts it was plastic, and in the pelvis, 
some little flakes were seen, swimming in serous fluid. The mesenteric glands were 
greatly enlarged, and also those along the psoas muscle and brim of the pelvis. 
Some of these were of a scirrhous hardness, others of a chalky consistence. Those 
on the brim of the pelvis were particularly enlarged, so as greatly to encroach on the 
dimensions of the superior strait. The uterus and its appendages had not contracted 
adhesions, both anterior and posterior pouches being entire. 

The situation of the stricture was a little more than an inch below the os ; and 
above this part, the vagina appeared thin and distended ; forming a continuous line 
with the dilated os, the circumference of which was above four inches. The cervix 
rapidly became thicker, and, for upwards of three inches towards the fundus, the 
parietes were fully double tneir normal size. The upper half of the body of the uterus 
was somewhat more bulky than natural, and its cavity slightly increased. The broad 
ligaments were unaffected, but their appendages were much less delicate than natu- 
ral. There was a cavity within the cervix, which formed the chief dilatation, so ex- 
panded as to be able to inclose a goose's-egor. The rugs and cells of the cervix were 
greatly diminished, and their surfaces presented a slight appearance of fibrinous effu- 
sion. Some few longitudinal striae were visible, more particularly at the posterior 
part, apparently the result of a recently-contracted cavity. 

The preceding case confirms the opinion, that operations about the 
vagina and perineum are occasionally followed by inflammation of the 
peritoneum ; and it ought to induce caution in the prognosis. The 
first division of the septum was not succeeded by mischief of any 
kind: yet, although there was no difference in the mode of operating, 
a second incision through the parts led to a fatal attack of peritonitis. 
The distention of the cervix, while the fundus and body of the uterus 
retained their normal form and size, is singular, and corroborates the 
statements, lately made, as to prolapsus of the neck of the uterus by 
stretching, and perhaps by growth, while the parts of the viscus, above 
the cervix, remain in their original state. If, as this case proves, 
effused fluid may distend and stretch the cervix, independently of other 
parts of the organ, it is not difficult to conceive that the same result 
may occur from other causes. 



Case 22. 
amenorrhea dependent on congenital absence of the vagina. 

Abridged from the case, as reported by M. Amussat, in the Gazette 
Medicale for December 12, 1835. 

A young lady, set. 15, was in bad health, owing to amenorrhcea. The menstrual 
effort occurred every month, but without, any discharge, and the abdomen was dis- 
tended by the gradually enlarging uterus. There was no vagina, but the urethra 
terminated naturally. A finger introduced into the rectum, and a sound passed into 
the bladder, detected the uterus, large and fluctuating ; and it was also ascertained, 
that there was so little space between the posterior part of the bladder and rectum, 
as to render it impossible, or very hazardous, to form an artificial vagina by the knife, 
lest these important viscera should be wounded. M. Amussat, the other medical 
attendants having given up the case as hopeless, proposed to separate the contiguous 
organs by traction. He began by depressing the mucous membrane of the puden- 
dum, just below the orifice of the urethra. Guided by a sound in the latter canal, 
he carried his finger onwards in the space between the rectum and urethra, and se- 
cured the ground he gained each day, by a properly adjusted sponge tent. At 



AMENORRHEA. 73 

length he reached the distended uterus, and, after a small opening by a trocar, he 
enlarged the os uteri, by a bistoury, keeping it open for some time by a canula. 
Menstrual fluid was evacuated, not only through the aperture thus formed, but also 
by a spontaneous opening through the rectum. The sequel of the case is encou- 
raging; the patient, entirely recovered, and, when the account was published, was 
not only menstruating regularly, but about to be married. 

Other cases of this kind may be found in the different medical authors. 

I forbear to enlarge the size of the book by the. addition of illustra- 
tive examples of the other forms of amenorrhoea. They are so com- 
mon and so well understood, and in some respects so closely resemble 
chlorosis, that the description of them in the text will suffice for their 
ready detection. 



Case 23. 
protracted amenorrhea cured by mercury. 

Mrs. H , set. 23, a native of the north of England, of dark and sallow aspect, 

and evidently unhealthy, was placed under my care in August, 1S23. Has been mar- 
ried between three and four years, but without pregnancy. Menstruation com- 
menced at fifteen ; but it has scarcely ever observed the regular periods, and it has 
occasionally been absent for several months together. 

Her present symptoms are amenorrhoea of seven or eight months' duration ; pro- 
fuse leucorrhcea, sometimes of bud odour; pruritus of the genitais, always severe, 
but occasionally so intolerable as to compel her to keep her own room. Constipated 
bowels, the evacuations dark, scybalous, and highly offensive ; healthy appetite de- 
stroyed, frequent craving for improper articles of food, and progressive emaciation. 
Skin of dark, icterode hue, lips and lining membrane of the mouth colourless. Pulse 
95 to 100, feeble and easily compressed ; frequent dyspncea, especially on the slightest 
pxertion, but there is neither thoracic pain nor cough. 

On inquiry, 1 found that Mrs. H. had been under the care of many practitioners, 
both in London and the country, and that nearly every plan of treatment had been 
tried, only excepting the mercurial. After explaining to herself and family, that as 
medicine had hitherto been unavailing, it was important at once to employ the most 
efficient means; I proposed that mercury should be exhibited to such an extent as 
to affect the system, and that soreness of the mouth and gentle salivation should be 
kept up for three or four months. I was the more induced to do this, because I found 
the uterus generally slightly enlarged, and the os and cervix hard, uneven, and ten- 
der to the touch. 

The patient was removed a few miles into the country, and on August 20th, 1823, 
commenced the following treatment. 

Sumat Pil. Hydr. gr. iij. Pulv, Opii gr. §■ in forma pilulse nocte, ma- 

neque. 
Infricand. Ung. Hydr. 9iss. inter femora quaque nocte. 

She was allowed wine and meat diet, and particularly enjoined to keep in the 
house and avoid cold. 

Sept. 10th. Gums very tender for the last two or three days, and there is decided 
salivation. There has been no menstrual effort. Complains of the inconvenience of 
the spitting, but the bowels are more regular, and the evacuations more healthy. 

Sept. 20th. The gums are not so tender, but they are slightly swollen and spongy. 
Has only taken three grains of Pil. Hydr. occasionally, just to keep up the effect. 
There has been no catamenial effort, but the pruritus is nearly gone, and her aspect 
is certainly improved. Appetite better. 

Oct. 20th. On the 17th of October, after some suffering, menstruation returned. 
and the flow continued for three days. In all respects better, and the family are 
struck with her improved complexion. 

Nov. 28th. Was ordered to discontinue the mercury, as it was thought the effect 



74 AMENORRHEA. 

would be maintained some weeks without its further exhibition. The catamenia re- 
appeared at the expiration of the month without pain; the discharge was abundant, 
and of sanguineous colour. No return of pruritus. On examination, I found the 
uterus less" heavy, and the os and cervix softer and less tender. Gargles for the 
mouth, sarsaparilla and bark, porter and wine, were freely given during the continu- 
ance of the treatment. 

In January, 1824, Mrs. H. was quite free from all mercurial influence, and in better 
health .than she had been for many years. In November, 1824, she gave birth to a 
boy, now (1839) living. 

For several years this lady remained healthy ; but she was subse- 
quently so much exhausted by excessive hemorrhage after childbirth, 
that dropsy supervened, and she died before she reached her thirtieth 
year. I could add similar cases, demonstrating the value of mercury 
in protracted amenorrhcea, and where there is congestion of the ute- 
rus. Dr. Davis relates several such in the first volume of his Princi- 
ples of Obstetric Medicine, one of the most valuable works of reference 
we possess. 



CHAPTER III. 

OF VICARIOUS MENSTRUATION. 

Definition. — A discharge, generally of blood, from other parts than 
the uterus ; superseding menstruation, and in its return, occasionally ob- 
serving a menstrual period. 

History and Symptoms.— This vicarious discharge can scarcely be 
regarded as a disease, when the hemorrhage does not really derange 
and exhaust the system. Dr. Locock calls it a curious freak of na- 
ture. I think he is right in doing so ; for the process, in most instances, 
equally wants the regularity of a healthy function, and the injurious 
influence of a disease. It is an event entirely out of course ; for al- 
though it is scarcely ever met with except in connexion with ame- 
norrhoea, still by far the greater number of instances of this latter 
malady are unaccompanied by vicarious discharge. Generally, it 
occurs in the unmarried, at least my observation warrants this con- 
clusion, butquite as often in the weak and delicate as in the robust. 
When married women are its subjects, conception rarely takes place 
during its continuance, although an interesting case, in which preg- 
nancy more than once suspended the vicarious discharge, is recorded 
by Dr. Davis. The sterility, depending principally on torpor of the 
organic system of nerves, may likewise be farther insured by the 
amenorrhceal state of the uterine lining membrane, incapacitating it 
for the formation of the decidua. The vicarious discharge is usually 
blood, but it may consist in an excess of the natural mucus of the 
genital organs, constituting leucorrhoea. Some portions of the pulmo- 
nary and intestinal mucous tissues are thought to be the more com- 
mon seats of the vicarious loss ; but certain it is, that the nipples, the 
ears, the gums, the umbilicus, the bladder, the axillae, any part of the 
skin, or the mucous membranes, or the surface of an open ulcer, may 
occasionally by gush, more usually by slow transudation for several 
days, furnish the vicarious blood. In the regularity of its periodical 
return, it seldom resembles the healthy function, although cases are 
recorded where the menstrual epoch has been exactly observed. 

It has been assumed, but without proof, that before furnishing the 
vicarious discharge, the part must be in a disordered, irritable, or 
weak condition; but it has been frequently seen, that so far from 
structural change taking place in the vicarious organ, even its func- 
tional disturbance is generally slight, and the amount of subsequent 
constitutional disorder is only proportionate to the blood lost. Where 
the nipples or mammae are the seat of the hemorrhage, there is often 
the formation of a crust over the affected spot, which being thrown 
off, the bleeding occurs. 



ryg VICARIOUS MENSTRUATION. 

The time during which vicarious menstruation may continue to be 
repeated, is very uncertain. I have admitted patients into Guy s ex- 
pecting its re-appearance, and after keeping them in the ward for 
many weeks, have been completely disappointed, the amenorrhea per- 
sisting, and the vicarious flow not returning. Local pain, constitu- 
tional irritability, and hysteria, are often premonitory of its periodical 
approach ; and in a patient, who was subsequently a nurse id l the > Hos- 
pital, the surface and edges of a large menstrual ulcer on the thigh, 
were invariably more painful, hot, and swollen, prior to its furnishing 
the vicarious evacuation. There are cases on record, by Gnurchill 
and Siebold, where excessive salivation has supplied the place ot the 
catamenia. Such an instance I have never seen. _ 

Causes —The suppression of an accustomed secretion, and the sud- 
den, or even the gradual supervention of plethora or congestion, may 
account for these local and vicarious losses. But why this form of 
menstruation should occur so rarely, if it be preventive or curative ol 
these morbid conditions, is a question which I cannot answer. 

Diagnosis.— The distinction can scarcely be difficult, between vica- 
rious and common hemorrhage. The existence of amenorrhea, the 
occurrence of marked catamenial effort and the vicarious evacuation, 
together with the absence of the local and constitutional symptoms 
of primary hemorrhage, will remove all doubt. 

Pr 0g no S is.~-I am not aware that any case has ever terminated 
fatally. So far as my observation has extended, the uterus has ulti- 
mately resumed its peculiar function, nor has the vicarious organ 
ever suffered any permanent injury. The duration of this curious 
process will much depend on the obstinacy of the amenorrhea, the 
effect of the vicarious loss, and the treatment. ' 

Treatment— The extent to which remedies shall be employed, must 
be determined by the amount of the hemorrhage, the effects ot the 
loss, and the warning of its approach. If the process has been fre- 
quently repeated, and there are premonitory symptoms, emmena- 
gogues may be used, if there be no plethora or congestion. It, now- 
eveV, there is engorgement of the uterus, cupping on the sacrum or 
loins, leeches to the os uteri, vulva or anus, must precede the use ot 
any stimulants. A smart drastic purgative may not only prevent the 
vicarious attack, but also induce menstruation; and I have several 
times, after preliminary depletion, witnessed the good effects of elec- 
tricity and the strong mustard hip-bath, at a high temperature. 

If the hemorrhage, having come on suddenly and without any pre- 
vious indication, is moderate, interference is unnecessary, the advan- 
tages of healthy menstruation being partially secured by it.. But it, 
on°the contrary, a large quantity of blood is lost, and from anorgan 
important to life, then similar measures must be adopted as in he- 
morrhage, not vicarious. The infusion of roses with nitrate of potass, 
dilute acid and digitalis, cubebs and bismuth, the acetate of lead, ergot, 
turpentine, and opium (vide formulae), may be exhibited. 

In the intervals, the treatment must be directed to the removal ot 
the araenorrhcea ; tonics, and especially iron, ought to be given. A 



VICARIOUS MENSTRUATION. 77 

residence at Tunbridge Wells, Malvern, Buxton or Matlock, or by the 
sea-side, is often decidedly advantageous. 

Vicarious Leucorrhcea. — There is in health a secretion, exceedingly 
small in quantity, of colourless transparent mucus, poured out by the 
uterine lining membrane, for the purposes of lubricating the opposite 
surfaces of the organ, and preventing friction and adhesive inflamma- 
tion. When excessive, constituting leucorrhcea, it is occasionally, and 
more frequently than blood, vicarious of menstruation. Strictly speak- 
ing, there is amenorrhcea, because a mucous, instead of a sanguine- 
ous secretion, is furnished by the minute extremities of the uterine ar- 
teries. But there is activity instead of torpor; and it will be found, 
on inquiry, that all the symptoms denoting menstruation regularly ap- 
pear, especially when this condition is vicarious of the catamenia at 
an early age. 

The disease is most common in delicate and susceptible girls, at the 
epoch of commencing menstruation. I have seen it also in weak and 
exhausted women, and I have now under my care a patient nearly 
thirty-five years old, who, in consequence of frequent abortion and 
protracted suckling, being exceedingly impoverished and feeble, has, 
for the last twelve months, suffered from vicarious leucorrhcea. The 
regular menstrual period has been exactly observed, and although the 
discharge has been fully as abundant as the natural catamenia, and 
has lasted three or four days, it has never till the last month been co- 
loured. Conception in these cases is not an improbable event, as in 
several females who have come under my notice, where the menstrua- 
tion was colourless, pregnancy has occurred. * 

In early life this vicarious leucorrhcea, if from its amount and pe- 
riodical return, it is believed to be uterine and not merely vaginal, re- 
moves all impression of congenital defect or malformation. Nor, if 
the interval be free from excessive mucous discharge, is the health 
much deranged : a circumstance marking the difference between this 
form of vicarious menstruation, and chlorosis and amenorrhcea. It 
rarely happens that the uterine function is fully developed indepen- 
dently of medicine or change of air, although it is quite possible that, 
under favourable circumstances, perfect menstruation may almost 
spontaneously occur. 

Pathology. — There can be no doubt that vicarious leucorrhcea depends 
not alone on disordered action of the secretory apparatus of the uterus, 
but also on the impoverished and attenuated condition of the blood ; 
and in those instances where the discharge is always present, we may 
probably infer the existence of sub-acute inflammation of the uterine 
lining membrane. It is difficult to explain by what diseased action it 
is, that vessels accustomed to eliminate a sanguineous fluid should so far 
lose their full secretory power as to furnish only an increased amount 
of mucus. Some years ago I pointed out a similarly perverted action, 
occurring after labour, where aqueous discharge, occasionally in im- 
mense quantity, is poured forth instead of the lochia. And in hemor- 
rhage from the intestines, an analogous phenomenon is sometimes pre- 
sented, when a large quantity of mucus, exhaled from the villous coat, 
supersedes the sanguineous flow. Dewees regards vicarious leucor- 
6 



78 VICARIOUS MENSTRUATION. 

rhcea as a slow development of the menstrual function. Friend and 
Astruc were both cognizant of its occasional existence. The former 
denominated it " the lymph-like menses," and Astruc recognises it as 
leucorrhcea taking the place of the catamenia. Nauche, in his com- 
prehensive, valuable work, ''Maladies propres aux Femmes,'' looks 
upon vicarious leucorrhcea as salutary, thus confirming the views I 
have guardedly expressed. He says that in 1824 he had under his 
care a patient, twenty-four years old, plethoric and robust, but healthy- 
sanguineous menstruation was absent. Instead of it, there was secre- 
ted every month, and with satisfactory results as regarded the health, a 
quantity of white mucus. 

Diagnosis. — The occurrence of the leucorrhcea at the monthly in- 
tervals, the other attendant circumstances, and the absence of healthy 
menstruation, will fully elucidate the character and origin of the ma- 
lady. 

Treatment. — This is nearly, if not entirely, the same as where he- 
morrhage is vicarious of menstruation. A nutritious and easily di- 
gested diet, exercise, pure air, and tonics, especially iron, will so far 
improve the blood and impart constitutional vigour, as sooner or later 
to induce healthy menstruation. 



CASES OF VICARIOUS MENSTRUATION. 

Case 23. 
reported by mr. ebenezer vorley. 

Sarah , aged 17, of short stature, fair complexion, and unmarried, became 

an out-patient of Dr. Ashwell, August 19th, 1836. Excepting an attack of intermit- 
tent fever, which occurred about four years ago, her health, though delicate, has 
been generally good. The catamenia first occurred two years since, while engaged 
many hours in the day at a sewing business ; twelve months elapsing before their se- 
cond appearance. Since this period, the function has been irregularly and scantily 
performed. Half a year subsequently to this return of menstruation, she had a vi- 
carious secretion from the breast, preceded by an effusion of blood under the skin of 
the mammse. '1 he cyst soon burst, and discharged its contents : a cicatrix partially 
formed, slightly pitted, and discoloured round its edges. The same process has been 
performed at every menstrual period since ; excepting on one occasion, when the 
catamenia appeared more naturally. The secretion is almost invariably from the 
left breast; the right only once having been similarly affected. The mamma* are 
much enlarged, exceedingly painful, and very tender a few days prior to the ex- 
pected period, at which time there are severe pains in the lower part of the abdomen, 
loins, and back. There is also abdominal swelling. It has several times happened, 
that there has been a very slight catamenial show, but it has not proceeded to a full 
menstruation ; and the breast, under these circumstances, has invariably performed 
its vicarious function. There is moderate leucorrhcea during the intervals, becoming 
excessive at the periods. She has little appetite; and, after food, suffers greatly 
from pain in the epigastrium, flatulence and heartburn. The bowels are very con- 
fined, requiring large doses of aperient medicine for their full evacuation. 

Pulse 108, feeble, and easily compressed. The tongue is coated with white fur; 
and her sleep is disturbed by pain in the inferior extremities and lower part of the 
abdomen. 



VICARIOUS MENSTRUATION. 79 

Let her use the Ammoniacal Injection daily; take the Colocynth and 
Calomel Pill three times a-week ; and the Mist. Ferri C. twice a-day. 

The treatment was continued for some months, her health gradually improved, the 
leucorrhoea disappeared, and in February, 1837 the catamenia were natural and re- 
gular. 

Case 24. 

August 20th, 1838. Miss , aged 17, a native of London, began to men- 
struate at 15, and after continuing to do so for a year, the discharge entirely ceased. 
Soon afterwards she had cough, and slight haemoptysis. The latter symptom disap- 
peared, and for the last six months she had vicarious hemorrhage from the ears. At 
the time I visited her, the blood filled the external meatus, and I was told by her mother, 
that the loss from both ears had never been less than three ounces at each period, 
and that it came slowly. By a piece of sponge 1 cleared the meatus, and afterwards 
I saw the blood slowly exhaling from the inner surface. As there were decided 
symptoms of chlorosis, and a feeble pulse, I ordered small doses of iron, an improved 
diet, and a visit to Tunbridge Wells. 

I did not see this patient again till several months after her return, but 1 had pre- 
viously heard that the vicarious discharge entirely ceased in two months, her health 
in the interval having been materially improved by the return of natural menstru- 
ation. 



Case 25. 
vicarious leucorrh02a. 

Mrs. L , aged 40, residing in Kent, consulted me on the 2d of August, 1838, 

for vicarious leucorrhcBa. She is thin, pallid, and extremely weak, although for- 
merly robust and embonpoint. Menstruation commenced at seventeen, and after 
her marriage, which occurred when she was thirty years of age, she frequently suf- 
fered from its scanty and painful return. She has had two children at the full term, 
and five miscarriages, alarming hemorrhage having attended every abortion. For 
the last year the menstrual period has been regularly observed, but the discharge has 
been less, and less sanguineous; and for nine months the secretion has been entirely 
bloodless. There is also considerable leucorrhoea in the catamenial intervals. Com- 
plains of extreme giddiness, and cannot occasionally stand upright. Pulse from 90 
to 110, weak and small, appetite nearly destroyed, and the bowels never act without 
medicine. Hysterical fits often occur, and she is nervous almost to insanity. 

She was ordered to the sea-side, a nutritious diet was enjoined, with a small quantity 
of wine and malt liquor; the salt-shower tepid bath, and constant exercise in the 
open air. 

R. Tinct. Ferri Muriat. Tinct. Humuli. Spir. Ammon. Aromatic, aa giv. 
M. ft. Mist. 

Take thirty drops in a tablespoonful of port wine three times a-day. 

A mild aperient when required; and a vaginal injection twice daily of sea-water. 

1 heard from this patient after a month's residence at Brighton: she was improved 
in many respects, but the vicarious leucorrhoea continued. She followed the plan 
laid down, and when she called at my house in December, having only a few days 
previously returned from the sea-side, she said that her health was perfectly re-es- 
tablished, but that the menstrual discharge was only slightly sanguineous. I enjoined 
a continuance of the iron. 



CHAPTER IV. 

OF DYSMENORRHEA. 

Definition. — Menstruation, preceded and accompanied by acute and 
often lancinating pain in the uterus and adjacent parts, and occasionally in 
the mamma, with derangement of the secretive function ; the catamenia 
being usually, though not invariably, scanty in quantity, and in the se- 
verer and more chronic cases, clotted, shreddy or membranous. 

History and Symptoms. — Dysmenorrhea is an important disease. It 
is very common, and produces extreme suffering — it often prevents 
conception; and if pregnancy has occurred during its continuance, 
the patient is exposed to the risk of abortion. Although, in itself, it is 
not a fatal malady, yet it admits of proof, that malignant diseases have 
followed its protracted existence; and lastly, it is exceedingly difficult 
to cure. It is not confined to one class of females ; the married and 
the single, particularly the latter, are obnoxious^ to it. It prevails 
among women of irritable temperament, and of delicate, strumous, and 
phthisical constitutions. The habits of the rich, therefore, by fostering 
these tendencies, have a direct influence in promoting it. There are 
examples too, although rare, among women of sanguine temperament. 
Every case of merely painful menstruation must not be regarded as 
dysmenorrhoea. If, for example, the pain and tightness of the head, 
the pain in the lumbar and hypogastric regions, which have preceded 
the menstrual period, diminish and pass away as the secretion in- 
creases ; such a case is not dysmenorrhoea. Scanty menstruation is 
not always painful; nor is the opposite state, where the function is co- 
piously performed, always free from suffering. Dysmenorrhoea is 
often coexistent with menstruation ; often after a prolonged and 
healthy continuance of the function, a change in the general system, 
or some of the exciting causes, to be mentioned hereafter, induce its 
approach. 

The earliest symptoms of irritable or neuralgic dysmenorrhoea, where 
there is neither inflammation nor congestion, are referable to general 
disorder of the health, such as impaired appetite, great languor, gra- 
dual loss of flesh, and uncertain action of the bowels. The catame- 
nia become irregular, sometimes appearing in excess, w T ith a prolonged 
interval ; while at other times suppression is an early morbid indica- 
tion. The discharge is emitted with almost indescribable pain, being 
shreddy, clotted, and generally scanty in quantity. These symptoms 
vary much in different cases. In some individuals, they are but tem- 
porary, continuing only for the first day or two of the period ; when 
after the expulsion of a small clot not always firmly coagulated, the 



DYSMENORRHEA. 81 

discharge assumes its natural consistence, and is unaccompanied by 
more than the usual local uneasiness. In others, the whole time is one 
of intense suffering, commencing with sharp, darting, lancinating pain 
in the uterus and vagina, and extending apparently to the uterine ap- 
pendages. There is acute sympathetic pain in one or both breasts; 
the lumbar pain, running down the sacrum to the thighs and groins, 
becomes extensive; and during the emission of the discharge, the ex- 
pulsatory pains, resembling the throes of labour, add much to the suf- 
fering. The intensity and duration of the pain depend much on the 
nature of the discharge, the rigidity of the structures, and the nervous 
susceptibility of the patient. In some instances, the catamenial period 
is preceded for two, three, or four days, or a week, by severe pain in 
the mammae. When the menstrual period has ceased, the suffering is 
for the time at an end, and the strength is less reduced than might have 
been expected. During the whole period, little febrile excitement ex- 
ists, and the amount of constitutional injury, from one or even several 
of these attacks, is inconsiderable. By and by, however, if proper 
treatment be neglected, or if the disease is so inveterate as not to yield 
to it, the general health becomes much impaired, and the reciprocal 
morbid action of the one upon the other greatly aggravates the case. 
Without any sympathies of the uterus, with the exception of the mam- 
mary being called into prominent exercise, the bowels become uncer- 
tain in their action, being sometimes constipated and then unduly 
relaxed, even from a mild purgative: the hepatic secretions are varia- 
ble in quantity; and occasionally there is pain and excoriation about 
the anus, from their acrimonious nature. The appetite is capricious 
and small, food is almost loathed, the blood becomes impaired, and 
imperfect nutrition is evident from paleness of the general surface, 
emaciation and loss of physical power. In this stage of the disease 
leucorrhoea becomes profuse, if it has not habitually existed; and some- 
times amenorrhea supervenes, thus entirely suspending the uterine 
suffering. In connexion with the continuance of this menstrual sup- 
pression, the mammae become flaccid and almost disappear, and the 
torpidity of the uterus excludes that viscus from a healthy discharge 
of its functions. 

In plethoric dysmenorrhea there is not much deviation from the symp- 
toms now described; but the menstrual period will be preceded by 
headache, flushing of the face, full and quick pulse, a sense of weight 
in the pelvis, rigours, and sometimes by delirium. These precursory 
symptoms are followed by the catamenia, which are sometimes profuse, 
with more or less of coagula. More frequently, however, the dis- 
charge is scanty, and consists of clots with portions of membrane, 
and the difficulty of emission is extreme. The pains resemble those 
of labour ; the patient bears down with considerable effort, and after 
many abortive attempts, a paroxysm of uterine suffering is relieved, 
by the expulsion of a small concrete clot, or a detached portion of 
membrane. It must not be supposed that only the plethoric women ex- 
pel these false membranes: women of an opposite temperament may do 
so, and for a lengthened period ; an ill-advised use of emmenagogues 
aiding such a result. 



g2 DYSMENORRHEA. 

Congestive Dysmenorrhcea.— When the affection of the mucous mem- 
brane is attended with a partial inability to secrete the full quantity of 
menstrual discharge, the large and repeated doses of aloes and steel, 
so often given with the intention of compelling menstruation, augment 
the quantity of blood in the uterus, which remaining stationary, every 
successive period is accompanied with an increase of congestion, till 
at length this form of the disease is fully established. The premoni- 
tory symptoms in this variety are comparatively slight. A sense of 
weight in the pelvis, with the bearing-down pains of prolapsus, lum- 
bar ""pain, frequent micturition and constipated bowels, denote an en- 
larged uterus. But it is not till the function is about to commence 
that the very severe symptoms arise. There is then intense uterine 
pain, with a sensation as though some foreign body were shut up in 
the uterine cavity; and in the attempts at its expulsion, the uterus 
is aided by the voluntary, as well as involuntary efforts. The pa- 
roxysms occur as in labour, but in dysmenorrhcea there is no interval 
of ease. Incessant restlessness comes on ; the patient looks anxious 
and pale, and frequently attempts to micturate, and as the contraction 
of the bladder is evacuating the urine, she uses all her power in the 
vain endeavour to expel a clot or portions of membrane. Some- 
times there is spontaneous relief afforded by the passage of a small 
concrete mass ; but this is temporary, and it is only with the cessa- 
tion of the period, that she can be said to be relieved from her suffer- 
ings. One marked peculiarity of this form is the absence of inflam- 
matory symptoms. The pulse is rather weak, sometimes quick and 
irritable, the skin is perspirable, and there is exhaustion, not inflam- 
mation. During the intervals of congestive dysmenorrhcea, where false 
membranes are constantly expelled, there is generally abundant leu- 
corrhceai discharge, the health becomes increasingly disordered, the 
mamma? shrivel, and the legs are cedematous. It is in this variety that 
spurious abortion most frequently occurs. A mass is ejected from the 
uterus, which is made up of a condensed or laminated coagulum with 
portions of membrane, or a membrane moulded to the cavity of the 
uterus, inclosing a large coagulum. Illustrations of these are beauti- 
fully delineated in Dr. Granville's work, and hereafter I shall give Dr. 
Montgomery's distinctions between this form of membrane and the 
true decidua. 

The late Dr. Mackintosh, of Edinburgh, pointed attention to dys- 
menorrhcea dependent on mechanical obstruction, caused by contraction 
or stricture of the canal of the cervix, or by partial imperforation of 
the os uteri. Capuron also alludes to it, and other authors think that 
in some very rare cases, the malady may be attributed to such a cause. 
There is no doubt that dysmenorrhcea has occasionally coexisted with 
such malformation ; but it is by no means certain that it owed either 
its origin or its continuance to such a state of parts as its cause. Dr. 
Churchill, in one instance, distinctly ascertained the presence of a 
stricture half-way up the canal of the cervix ; but its dilatation left the 
dysmenorrhcea as bad as before. A few years ago I examined the 
cervix after an extremely severe and protracted attack of the dis- 
ease, and I satisfied myself and a professional friend, that there was 
really narrowing of the canal. This was entirely cured by bougies; 



DYSMENORRHEA. 83 

but the catamenial suffering was not at all alleviated. In another case 
I was more successful, and Dr. Ryan entirely cured one of the very 
bad forms of dysmenorrhea by metallic bougies. In Dr. Mackin- 
tosh's examples there is nothing proved as to retention of the menses, 
which might have been looked for if the mechanical impediment had 
been so complete as " scarcely to admit a bristle." He tried the treat- 
ment by bougies in twenty-seven instances, and cured twenty-four. 
In eleven of the latter number, pregnancy subsequently occurred. As 
the introduction of bougies must act as a direct and powerful uterine 
stimulus, the advantage, even where contraction really exists, is not 
necessarily entirely attributable to dilatation. In doubtful cases an 
internal examination ought to be made ; as dysmenorrhea may de- 
pend not only " on a small os, but on inflammation of the lining mem- 
brane, and of the neck of the womb, and on tumours diminishing the 
calibre of the passage through the cervix." Still I believe that the 
views of Dr. Mackintosh are more correct than is generally supposed, 
and they should not be disregarded in protracted and obstinate dys- 
menorrhcea. 

Causes. — It is not at all times easy to specify the exciting cause. 
The history usually brings to light some symptoms of uterine irrita- 
tion, more or less acute ; some catamenial irregularity, some proof of 
a temperament disposed to strong emotions. Among married women, 
miscarriages, premature confinements, and particularly the various ef- 
fects of cold, may be enumerated as preceding the complaint. Nor 
must uterine determination or congestion be forgotten, by some patho- 
logists regarded as the most frequent cause of all. 

Diagnosis. — But little need be said on the diagnosis of dysmenor- 
rhea; as in the great majority of cases, the functional disorder is clearly 
ascertained, and the symptoms well defined. It is only in the cases of 
spurious abortion, where the characters of individuals may be igno- 
rantly aspersed, that much discrimination is required. The duration 
of the complaint, the nature of the menstrual secretion in former 
periods, the enlarged state of the uterus from congestion, as ascer- 
tained from examination by the vagina and rectum, independently of 
the physical characters of the product, are quite sufficient to satisfy 
any observer. Dr. Montgomery, in his elaborate and accurate work, 
on " The Signs and Symptoms of Pregnancy," thus expresses him- 
self, in reference to the peculiarities which distinguish the dysmenor- 
rhea! membrane. 

"The substance expelled in this disease will be found deficient in 
several of the properties of the true decidua ; for although produced 
by an action in the uterus analogous to that by which it prepares the 
decidual nidamentum for the reception and support of the ovum, it 
differs therefrom in two essential points : first, that it is a morbid pro- 
duct ; and secondly, that not being intended, like the true decidua, to be- 
come an organ, or at least a medium of nutrition for the ovum, it is not 
furnished with a structure such as would only be required for the per- 
formance of such an office ; hence, it is thin, flimsy, and very unsub- 
stantial in its texture ; of a dirty-white or yellowish appearance when 
slightly agitated in water, devoid of the soft, rich, pulpy appearance, 



84 DYSMENORRHEA. 

deep vascular colour, and numerous foramina for the reception of the 
nutrient vessels from the uterus, which are always so distinctly obser- 
vable in the true decidua, which however in one point it resembles, 
having its inner surface smooth, and the outer unequal, but of a ragged, 
shreddy appearance, unlike that of the healthy uterine decidua, and it 
is, moreover, entirely destitute of the little cotyledonous sacculi already 
described as an essential character in the latter structure. In texture, 
it more nearly resembles that of the reflexa than any other structure ; 
but no trace of the transparent membranes of the ovum can be dis- 
covered within it, or attached to it, and should it happen to come 
away entire, in the form of a hollow triangular bag, we never find 
within it a duplicature of itself forming an inner pouch or reflex layer, 
as in the case of the natural decidual envelopes of the ovum." Mor- 
gagni has given a very accurate account of this accidental product, as 
it occurred in the case of a noble matron of his country, who expelled 
it almost every month with pains like those of childbirth, having its 
external surface " unequal and not without many filaments that seemed 
to have been broken off from the parts to which they had adhered; but 
internally hollow, on which surface it was smooth and moist, as if from 
an aqueous humour which it had before contained." 

Pathology. — Some authors regard dysmenorrhoea as a neuralgic 
affection, a disease of enervation, identical with hysteralgia and irri- 
table uterus. Others take a different view of the malady, and consi- 
der it as invariably dependent on a morbid condition of the mucous 
lining of the uterus. The former attribute the pain, and all the other 
symptoms, to acute irritation ; the latter, to inflammatory action. 
These conflicting opinions are not irreconcilable. In a great num- 
ber of cases, particularly in delicate single female's, there is only acute 
nervous irritation, affecting the muscular tissue as well as the mucous 
lining, and producing pain. In other and aggravated examples of 
the malady, there exists a low form of inflammation, modified by the 
peculiar membrane which it affects, and inducing intense pain. There 
are facts strengthening the impression, that dysmenorrhea is often a 
disease of irritation. Hysterical and susceptible females are more 
prone to it than any other class. The pain is mostly unaccompanied 
by symptoms of inflammation ; the pulse is quickened only during the 
paroxysm ; this being over, it again subsides ; and the flushed face 
and hot skin are often succeeded by a cold and clammy surface. 
Acute pain may exist without inflammation, and a layer of lymph 
may, as in dysentery, be thrown off' from the intestinal mucous surface, 
without decided inflammatory action. Neither the pain of labour nor 
the after-pains, occasionally so protracted and agonising, are inflam- 
matory : and yet if the degree of pain were to be the criterion, one 
might easily believe that inflammation really existed ; for certainly no 
suffering from dysmenorrhoea can be greater than the pain attendant 
on labour and its' subsequent contractions. In other cases, and which 
are thought (by the supporters of the opinion that inflammation is in- 
variably present), alone to deserve the appellation of dysmenorrhoea, a 
modified and low form of inflammation certainly exists, which pro- 
duces a false membrane, assuming, in some instances, the shape of 



DYSMENORRHEA. 85 

the uterine cavity, and in others, being expelled in detached portions. 
I quote the following remarks from a clear and practical paper on 
this malady, read before the Medical Society of Guy's Hospital in 
1839, by Mr. Henry Oldham, one of the obstetric assistants of the in- 
stitution. 

u There are so few instances in which minute investigations of the 
exact condition of the mucous membrane and body of the uterus in 
dysmenorrhea are permitted, that we cannot offer any remarks on 
the visible changes in these structures. We are consequently left to the 
far less secure, but the only admissible mode of inferring the charac- 
ter of these alterations, from the symptoms which accompany the af- 
fection and the analogous productions from other mucous membranes. 
There can be no doubt that mucous membranes, though prone to sup- 
purative inflammation, often throw off from their surface false mem- 
branes of organised lymph. The trachea in croup, the intestines in 
some forms of dysentery, the urethra under inflammation, are familiar 
examples of the kind ; and there is but one common explanation of 
this occurrence, viz., that the products of inflammation are present, 
and that the lining membranes of these several organs are the seat 
of the diseased action. The uterus presents a precisely analogous 
instance in dysmenorrhea, and we hence infer, that its mucous lining 
is in a similar state." 

A paper presented to the Statistical Society in 1839, by Mr. Lever, 
another of the obstetric assistants of the Hospital, and displaying his 
usual research, confirms these views, by showing that one of the oc- 
casional ultimate results of dysmenorrhea, is structural change of the 
uterus. A protracted dysmenorrhea, where the false membrane has 
been habitually secreted, and the fact will be noticed in the appended 
cases, is liable to induce thickening and induration of the os and cer- 
vix. This is the result of chronic inflammation, and it is only to be 
feared from the probability of its assuming a malignant character in 
women possessing a cancerous diathesis. By such a structural change, 
whenever it affects the channel of the cervix, mechanical dysmenor- 
rhea may be induced. 

Prognosis. — This w r ill be more or less favourable, according to the 
views entertained of its nature. If, like irritable uterus, dysmenor- 
rhea be regarded as invariably a neuralgic, not* an inflammatory dis- 
ease, it may be severe and protracted, but it will not be fatal. In 
fact, I know of no instance w r here a termination so serious has been 
its immediate result. But, if a scirrhous or carcinomatous change of 
the uterus follow, even very rarely, in its train, then a prolonged dys- 
menorrhea is a great evil. It must not, however, be forgotten, that 
in the majority of instances, the affection is cured, either by medical 
treatment, marriage and childbearing, or by the natural permanent 
cessation of the catamenial function. From observation, I am dis- 
posed to think, that marriage and connubial intercourse are frequently 
remedial ; the probability or impossibility of such events must there- 
fore influence the prognosis. It is not meant to be affirmed, that they 
are invariably curative, or that aggravated examples of the affection 
are not to be found amongst married women. I am now attending 



86 DYSMENORRHEA. 

an unmarried patient in her forty-fifth year, who, from fifteen to forty- 
two (when the function entirely and suddenly ceased), invariably 
suffered from dysmenorrhea. Her sister was similarly affected till 
her marriage, but that event, and frequent pregnancy, entirely dis- 
placed and cured the dysmenorrhea. In the former case, I have ex- 
amined the uterus very carefully, but I cannot discover any structural 
change either in the body, cervix, or os. The utmost caution should 
be used in the investigation of suspected structural change supposed 
to be connected with dysmenorrhea, as, in the opinion of the sex, 
very little suffering is sufficient to induce them to denominate any case 
painful menstruation. A few years ago, it was a matter of doubt 
whether the false membranes of dysmenorrhea could be formed in- 
dependently of impregnation. This point is now laid at rest, and no 
suspicion can for a moment be entertained of the purity of any indi- 
vidual so circumstanced. It has been thought, too, that conception 
was entirely incompatible with this disease. I have known preg- 
nancy occur in several instances, almost immediately after the mar- 
riage of a dysmenorrheal patient; but it cannot be doubted, that an 
aggravated form of the malady must be unfavourable to such an 
event, and that sterility may often be fairly attributed to such a cause. 

Treatment. — This is necessarily different; for, while inflammatory 
and congestive dysmenorrhea require depletion and antiphlogistic 
measures, the neuralgic or irritable form calls only for narcotic and 
slightly nauseating remedies. There are, however, in the treatment 
of every variety, two principal indications : to alleviate the urgent pain 
of the menstrual period, and to employ, during the intervals of the dis- 
charge, such remedies as shall restore to the uterus its healthy secre- 
tory power. Both are occasionally accomplished with difficulty ; the 
first, however, is generally the most easy of fulfilment. 

In the more ordinary variety of the malady, the neuralgic, the mus- 
tard hip-bath and some narcotics are especially beneficial; if the attack 
be aggravated or of frequent recurrence, then ipecacuanha or antimony 
ought to be employed. But to be more precise : let the patient, on the 
first premonition of pain, commence the use of the hot bath at 96° or 
9b°, and ordinarily remain in it for a half or three-quarters of an hour, 
repeating it three or four times in the twenty-four hours, and always 
guarding against the effects of cold, by keeping in a hot bed, so long 
at least as to allow the skin to resume its ordinary temperature. When 
the pain is very severe, the bath may be continued until faintness is 
induced ; and if it be inadequate for this purpose, then half a grain of 
ipecacuanha, or fifteen or twenty drops of antimonial wine, may be ex- 
hibited every hour. It will be found, that the general relaxation of the 
cutaneous surface, and the attendant and temporary depression of the 
system, greatly favour menstrual secretion. In the milder cases, a 
hot hip-bath and slight narcotics will suffice. Camphor, ipecacuanha, 
and hyoscyamus, the Dover's powder, the extract of hop, lettuce, co- 
nium and belladonna, variously combined (vide formulae), relieve the 
pain and induce perspiration and sleep. If perspiration is with diffi- 
culty obtained, three, or four, or five grains of antimonial powder may 
be given, by which a diaphoretic effect will be insured. Sometimes, 
when the pain is terribly severe, and the cerebral excitement goes on 



DYSMENORRHEA. 87 

nearly to delirium, one-quarter or half a grain of the acetate of mor- 
phia may be given at night ; and smaller doses, either of it, the muriate 
or meconate of morphia, or Battley's Liquor opii sedativus, at intervals 
during the day. A suppository of opium, conium, hyoscyamus or 
belladonna, is often effectual in relieving the pain. In some cases, 
from the forcing, bearing-down efforts, we can distinctly recognise the 
attempt on the part of the uterus to expel a clot. Here the ergot, 
either in decoction or tincture, may be repeatedly given, and an inter- 
val of marked ease, however brief, will occasionally follow its expul- 
sion. It would be difficult to speak with precision of every modifica- 
tion of treatment ; but enough has been said to enable the practitioner, 
while he maintains the principle, to vary the mode of management. 
In a French publication of the Society of Agriculture, Sciences, and 
Arts, Dr. Patin recommends the acetate of ammonia for dysmenorrhea ; 
enjoining, however, this caution, that as it diminishes the discharge, it 
must be used with reserve. He says, that so far from being a stimulant, 
it is really a sedative remedy ; and he regards it as applicable in any 
case, whether of dysmenorrhcea, profuse menstruation, or menorrhagia, 
if there be morbid excitement of the female genital system. This phy- 
sician gives from forty to seventy drops three or four times daily ; the 
only inconvenience being slight and transient giddiness. I have no 
experience of this remedy.* 

In the inflammatory and congestive forms of dysmenorrhcea, in addi- 
tion to the remedies already enjoined, local depletion is peremptorily 
required ; and there are cases, where there is vascular fulness, in which 
a small general bleeding will be advantageous. Congestion almost 
invariably prevents secretion ; the unloading of the vessels, therefore, 
aids the flow of the discharge. In the majority of instances, cupping 
on the loins, to the extent of eight, ten, or twelve ounces, or leeches, 
will suffice, and, if necessary, the bleeding may easily be repeated. 
Leeches to the os uteri have been already mentioned, and I think, that 
when well applied, they are decidedly more beneficial than any other 
local depletion. Several times I have witnessed their superior efficacy 
in relieving the severe pain; in one instance, where the patient had been 
in the habit, for several years, of being occasionally cupped, the relief 
afforded by thus directly unloading the congested vessels themselves, 
exceeded, to use her own expression, any idea she could have formed. 
The speculum tube may be introduced into the vagina prior to their 
application : and if the cervix be brought fully into view, neither the 
vagina nor any other part than this portion of the congested viscus will 
be fixed on by the leeches. Their use should, as much as possible, be 
confined to married women, and a clever nurse should be taught to 
apply them. The hot bath, as heretofore advised, sudorific, nauseating 
and anodyne medicines may all be used. Hot poppy fomentations to 
the abdomen generally, and particularly to the hypogastric region, in- 

* This remedy is the Spiritus Mindereri, and is usually given to adults as a seda- 
tive diaphoretic in fevera, in tablespoonful doses. A short time since a patient of 
mine was taking a tablespoonful of this remedy, three times daily, who has laboured 
under dysmenorrhcea for several years, and she had a menstrual period free from 
pain. She has since menstruated with much less pain than formerly. I know not 
to what this effect is to be attributed if it be not the acetate of ammonia — G. 



88 DYSMENORRHEA. 

jections, several times during the twenty-four hours, of poppy and 
conium into the vagina, so as constantly to bathe the lower part of the 
uterus, will encourage the discharge and soothe the pain. 

The second part of the treatment comprises the management during 
the catamenial intervals. In the neuralgic and irritable form of the 
disease, the object is to improve the general health, principally by at- 
tention to the disordered state of the digestive organs, and by the avoid- 
ance of local excitements. I need not dwell on the importance of 
mild and cordial aperients, in preference to drastic and mercurial pur- 
gatives. An occasional alterative, such as the gray powder, or a mode- 
rate dose of blue pill, is required, but active and repeated purging must 
be injurious. Afterwards the various preparations of iron, combinations 
of the mineral and vegetable tonics, omitting them when the bowels 
are disposed to be relaxed, a nutritious and unstimulating diet, pure 
air, a temporary residence at places celebrated for their chalybeate 
waters, and gentle but persevering exercise, are the most important 
indications. Dr. Dewees, one of our ablest obstetric writers, regards 
the neuralgic form of dysmenorrhea as analogous in its nature to chronic 
rheumatism ; and strongly recommends, in the intervals of the disease, 
the volatile tincture of guaiacum ; adding, that he has relieved many 
dysmenorrhoeal patients by the antiphlogistic plan, but cured none. He 
begins with drachm doses of the tincture three times daily, increasing 
the quantity to three drachms three times daily, in a glass of wine. His 
success has been great ; mine, although I have often tried the guaiacuwi, 
has been inconsiderable. 

In the inflammatory, and especially in the more frequent cotigestive 
form of dysmenorrhea, local depletion, saline aperients, and spare diet, 
are particularly necessary ; nor should they be discontinued till the 
volume of the uterus is satisfactorily lessened. The hot hip-bath three 
times a-week, and warm injections of the fotus papaveris twice a-day, 
will topically aid the former and more important remedies. After- 
wards, mild tonics will complete the restoration of the patient. Bear- 
ing in mind what has been already said, of structural uterine change 
following chronic dysmenorrhea, mercury must not be forgotten in the 
inveterate cases. In the preceding chapter, when treating of its deob- 
struent effects, I pointed out certain conditions as unfavourable to its 
use ; but, where these indications are absent, there is no medicine so 
likely to prove efficacious. It may be employed in both the varieties, 
if their continuance is exceedingly prolonged, and the false membrane 
is habitually expelled ; but certainly mercury is most beneficial where 
there is a thickened and indurated cervix, the result of chronic inflam- 
mation.* 

* A plan has been pursued in this city with various success, and I think it the best 
which I have used, except the artificial dilatation of the neck of the uterus by houses. 
This is, to wive the patient about one-eighth of a arain of extract of belladonna three 
times a-day, commencing about a week before the menstrual effort, and continuing 
until the pupils are slightly affected or the discharge commences. If this plan is 
pursued faithfully for six m eight menstrual periods, it will very freq uently suc- 
ceed. With regard to dilatation, I am stire that four out of five cases of dysaiencr- 
rhoea may be permanently relieved hy it; and there is strong reason to believe that 
the cures made by childbearirg, or even abortion, owe their results to this cause, 
namely dilatation. — G. 



DYSMENORRHEA. 89 

The effect of the inunction of the iodine ointment on the neck of the 
uterus, where it is enlarged and hardened, is most satisfactory. This 
subject will, however, be more fully treated of in the chapter on hard 
tumours of the os and cervix. 



Case 26. 

CHRONIC DYSMENORRHEA PREGNANCY SUPERVENING AFTER FOURTEEN 

MONTHS. 

OCCURRING IN THE PRACTICE OF MR. HENRY OLDHAM. 

Oct. 20. Mrs. H , a young lady of lively, active habits, was married in 

July, 1838. For three or four years previous to her marriage, she appeared consti- 
tutionally delicate, and during this time she suffered from occasional menorrhagia, 
followed by menstrual suppression, the continuance of which varied between six 
weeks and two months. This condition of the uterine function was attended with 
great languor under exertion, imperfect nutrition from loss of appetite, irregular action 
of the bowels, tympanitis, hysterical emotions, and leucorrhoea more or less profuse. 
During the latter part of this time she had several attacks of glandular swellings, and 
the right lobe of the thyroid remains permanently enlarged. 

The first three months of marriage were attended with marked improvement in her 
general health. The appetite became healthy, the features firm, the animal spirits 
buoyant, and everything indicated confirmed health. About the fourth month after 
marriage the first symptoms of dysmenorrhcea appeared. The menstrual period was 
preceded by intense pain in the mammae, lasting for days, which was relieved only 
when the catamenia commenced to flow. The discharge itself was altered in quality, 
being clotted, and in its expulsion occasioned much local suffering. The pains, 
however, subsided with the discharge, and the first periods were passed, leaving 
only a temporary sense of exhaustion. IShe came under my care in March, 1839. 
At this time she was labouring under an attack of dysmenorrhcea, which had been 
preceded by great irritability of the mammae, lasting eight days. The local suffer- 
ings were very great, and the discharges consisted of occasional fibrous masses, with 
detached portions of membrane and a brownish-coloured fluid. During the attack 
she complained much of exhaustion, her appetite left her, and the least exertion 
aggravated the pain. She was ordered the hot hip-bath, with hot poppy fomentations, 
and the following pills: — 

R. Ext. Hyoscy. gr. iv. 

Camphorse Rasee, gr. iij. 

Pulv. Ipecac, gr. i. Ft. PiluL ij. Ter in die sumend. 

These had the desired effect of relieving the pain ; but the symptoms after the 
catamenial period did not kindly pass away. There was continual aching of the 
loins and groin, as though the uterine ligaments were strained ; a perpetual, sense of 
weariness; indifferent appetite; and unrefreshing sleep. She also complained of 
pruritus of the external genitals, and leucorrhcea was present. The bowels were 
irregular, sometimes constipated, and at others relaxed. Circulation feeble. 

It would be tedious to recount even a monthly report, although the symptoms were 
accurately noted. They partook generally of those already "enumerated. At one 
time the tonic treatment pursued during the interval seemed almost to have re-estab- 
lished her health ; but the intense agony of the succeeding period left the same ex- 
haustion ; and was followed by the same constitutional effects. The sedative treat- 
ment, with slight variations, was enjoined during the attacks, and chalybeate? va- 
riously combined — occasional purgatives, with good, but unstimulating diet, were 
the main therapeutics in the intervals. She was ordered to the sea-sideband marital 



90 DYSMENORRHEA. 

» 

intercourse was suspended. Temporary alleviations were often procured ; but there 
still remained delicacy, and continual ailment with the same functional disorder. Her 
general health, indeed, seemed gradually to get worse; and some of her friends fore- 
boded phthisis, without, however, any physical sign of thoracic disease being recog- 
nised. Iodine, with the hydriodate of potash in small doses, was given with some 
benefit; and the iodide of iron had a decidedly good effect. 

In September, 1839, she menstruated naturally, without antecedent pain; and the 
discharge was of its proper consistence, colour, and quantity, and the appetite greatly 
improved. In a fortnight after this period she complained of more intense suffering 
than she had ever before experienced, in the hypogastric region, with lumbar and 
bearing-down pains, inability to exert herself, etc. The mamma? also became in- 
tensely painful, so that the least pressure on them occasioned shivering and sudden 
pallor. On examining the uterus, the os and cervix were found hardened and pain- 
ful, and the body of the uterus fuller than natural, its weight being sufficient to bear 
it low down in the vagina. A previous examination, about six weeks before this time, 
had detected the os and cervix larger than normal ; but soft and rather painful when 
even gently touched. The local and sympathetic pains seemed to be premonitory of 
the menstrual flow ; but this period passed away, and ten days afterwards Dr. Ash- 
well saw her with me. On examination, the volume of the uterus was found consi- 
derably augmented, and it was suspected that this suspension of the catamenia had 
occasioned the congestion. Upon more careful examination, however, of the mammae, 
a well-formed areola was visible, and the existence of pregnancy became probable, 
and now, in November, the sympathetic affections have abundantly confirmed the 
opinion. 



Case 27. 
protracted dysmenorrhea cured by mercury. 

In January, 1837, 1 visited Mrs. , aet. 24, residing a few miles from town. 

She is delicate and of strumous aspect, and has been married nearly two years. She 
aborted soon afterwards, and has never since been pregnant. The present symptoms 
are intensely painful menstruation, accompanied by the expulsion of clots and por- 
tions of false membrane. Prior to marriage she suffered in a similar way, but not to 
the same extent. For a few months after this event, the dysmenorrhoea was mate- 
rially alleviated ; but since the abortion it has returned in an aggravated degree. 
Now, pains in the hypogastrium, loins, and thighs, occur several days prior to men- 
struation, inducing fever and depriving her of appetite and sleep; the dysmenorrhoea 
lasts seven or eight days, and from exhaustion she is generally on the sofa a week 
afterwards; so that the disease and its consequences absorb nearly the whole month, 
and leave but little opportunity for curative treatment. Leucorrhoea is always pre- 
sent when she is not menstruating; the bowels are irritable and uncertain ; some- 
times constipated, and at other times, after a gentle aperient, or even after trivial 
mental excitement, violently purged. 

In May, Mrs. was no better, although she had fully pursued the treatment 

laid down in the previous pages. She was emaciated, and as she complained of con- 
stant heat and pain at the neck of the bladder, and of pain also in co'itu, I was allowed 
to examine. The lower part of the body of the uterus was enlarged, hard, and slightly 
tender ; the cervix was thickened, generally increased in size, indurated, and uneven, 
but without the stony hardness of malignant disease; the os was patulous, and its 
edges not smooth. The whole viscus was increased in size, and on raising it up on 
the finger, she was immediately relieved from pressure on the neck of the bladder, of 
which at other times she complained. 

I now urged the importance of the mercurial treatment, the recumbent posture, and 
the entire avoidance of sexual intercourse. 

June 20. Mrs. was ordered three grains of blue pill every night ; and four 

ounces of the compound decoction of sarsaparilla, with two grains of quinine, twice 
a-day. Meat diet and mild ale ; and she was also especially enjoined to be careful 
not to expose herself to cold. 



DYSMENORRHEA. 91 

July 24. The mouth has been affected, and the flow of saliva increased for the last 
fortnight; but there has been neither premonitory pain nor menstruation, although 
more than a month has elapsed since the last period. In other respects there is not 
much alteration ; the countenance is still wan and anxious. 

August 10. Menstruation has occurred with much less pain, and without either 
narcotics or the warm bath. Gums are sore, and the salivation is still going on, al- 
though one three-grain pill only is taken every third night. 

Sept. 25. Has entirely discontinued the mercury for several weeks, and the 
last two periods have been passed with scarcely any pain, and without clots or mem- 
brane. 

I have twice examined the cervix uteri, and although it is still tender, the indura- 
tion is gone, and the size of the uterus and of the cervix also are again natural. This 
patient afterwards spent a considerable time in the country and by the sea-side, en- 
tirely recovering her health and strength. 



Case 28. 

SEVERE DYSMENORRHEA DEPENDENT ON INFLAMMATORY CONGESTION OF 

THE CERVIX AND BODY OF THJE UTERUS. 

OCCURRING IN THE PRACTICE OF MR. FENNER OF PENTONVILLE. 

Miss W , aged 29, began to menstruate so favourably at seventeen years of 

age, that she was unconscious of the occurrence. But after some months, she inva- 
riably suffered (and has continued to do so to the present year, 1839), a few days be- 
fore the periods, from acute pains in the loins and left hypochondrium, headache, 
flatulence, retching and violent palpitation of the heart. The pain in the left hypo- 
chondrium and the palpitation have since been almost constantly present in greater 
or less degree. The periodical discharge is always dark, scanty, clotted, and mem- 
branous, never lasting more than a day and a half, and sometimes not so long. Durino- 
the year 1838, there were superadded a shooting pain on the inside of the left thiuh° 
leucorrhcea, and intense pruritus, rendering the condition of the patient extremely dis- 
tressinu-. 

Sept. 20, 1839. A period has just passed with such aggravation of the above 
symptoms as led to my being consulted. On examining the uterus by the speculum, 
I found its cervix and body considerably congested, and very painful to the touch. 
Moderate pressure with the finger instantly re-produced the palpitation of the heart', 
and the pain in the left hypochondrium, causing the patient to exclaim " Oh my heart! 
how it beats !" Then, "Oh my side! you are bringing on the pain in my side!" 
thus demonstrating that those sensations were merely sympathetic of the condition of 
the uterus. 

Treatment.-— She was bled to fifteen or sixteen ounces— a pill of Pulv. Antimon. 
gr. iii. Antimon. Pot. Tart. Hydr. Chloridi. aa. gr. one-sixth, was given every six 
hours until the month became sore ; afterwards it was continued once or twice daily, 
to maintain the derivative action, up to the time of the next period. A hip-bath, and 
an injection of warm water into the vagina, were used twice every day while the pains 
continued severe,— then every night. The patient was enjoined to keep much in 
her bed, and to use the Hydrocyanic lotion (vide formulae) for the pruritus. Ex- 
ternal irritation was also kept up on the left hypochondrium by the Una. Antimon. 
Pot. Tart. ° 

Sept. 29. Much better ; pulse 90, and less irritable ; mouth sore ; pain in the left 
hypochondrium, and palpitation less. 

Oct. 1st. On examination by the finger, the uterus is found to be much softer, 
and less sensitive; nor even the pain and palpitation produced, as before, by pres- 
sure. 

Oct. 17. As the period was expected to return very shortly, the patient was again 
moderately bled, complaining only of slight premonitory pain in the hip and head. 
She has suffered less during the interval than for years ; her appetite and sleep being 
greatly improved. 



92 DYSMENORRHEA. 

Oct. 23. After passing a good night, and getting op well, the catamenia appeared, 
as at first, unconsciously and without pain. 

It would be easy to verify the statements of the text by a far greater 
number of cases, as examples of the disease in its different forms, and 
of every degree of severity, are continually presenting themselves in 
private and hospital practice. But the instances cited may suffice to 
impress the importance of a correct view of the precise pathological 
condition of the uterus before commencing any active treatment. Nor 
can it be too strongly urged, that as pain is the accompaniment of so 
many different morbid conditions, it is in dysmenorrhoea absolutely essen- 
tial to know whether it be associated with an irritable and neuralgic, or 
an inflamed and congestive uterus. Palliatives and narcotics may suf- 
fice in the former varieties, but in the latter, till inflammation and con- 
gestion be removed by depletion and antiphlogistic measures, neither 
narcotics, tonics, nor emmenagogues will avail. 

I have already spoken of the advantages of leeches directly applied 
to the cervix uteri, when the dysmenorrhoea can be traced to congestion ; 
and I have lately seen several cases, one in particular, with Mr. Fenner 
of Pentonville, who devotes much time to the investigation and treat- 
ment of female sexual disease, where, by the aid of his speculum tubes, 
scarification of the neck of the uterus was freely practised. There was 
not during the operation, nor afterwards, any decided pain ; and as three 
or four ounces of blood were quickly drawn, it will prove a far better, 
quicker, and less troublesome remedy than the application of leeches : 
the relief attendant on 'this novel process, was superior to what had ever 
resulted from the leeches. I believe this method of depletion may be 
safely, and often most advantageously, resorted to. 



CHAPTER V. 

FORMULAE OF REMEDIES. 

It may not be without advantage that I should select, from the various 
remedies used in hospital and private practice, in the diseases already 
described, all of which are distinguished by paucity of the catamenial 
discharge, those which, after repeated trials, I have found most effi- 
cient. 

APERIENTS AND PURGATIVES. 

Form 1. — Pulv. Magnesias Comp. 

R. Magnesias Sulphatis 3 iss. Magnes.Carb. Sodas Sesqui Carb. aa Jiv. 
Sodae Hydrochlorat. gij. Pulv. Zingib vel pulv. Aromatici 3j. M. ft. 
Pulvis. 

Take one, two, or three teaspoonfuls at bed-time, or occasionally in the 
day, when the bowels are confined. Usually the powder may be mixed 
in warm water; but if a more decidedly aperient effect is desired, then half a 
bottle of soda water may be poured over the salt, and it may be swallowed in 
a state of effervescence. 

Form 2. — Pulvis Purgans. 

R. Pulv. Rhei gr. yj. Potassae Sulphatis vel Sodae Sulphatis gr. x. Pulv. 
Zingib gr. iij. 01. Cassias gtt. ij. M. ft. Pulvis Purgans. 

Take one powder in warm water night and morning. 

Form 3. — Pulvis Purgans. 

R. Hydr. Chloridf gr. ij. Pulv. Jalapae, gr. vj. Pulv. Cambogias gr. iij. 
Pulv. Zingib gr. iv. Olei Cassias gtt. ij. M. ft. Pulv. 

Take one powder in gruel, or barley-water, once or twice a-week, at bed- 
time. V 



Form 4. — Pulv. Scamrnonese cum Hydr. Chlorid. 

R. Scammon. Gum. Resin. Pulv. gr. viij. Hydr. Chloridi gr. ij. vel iij. 
Potassae Supertart. Sacch. Alb. aa gr. x. M. ft. Pulv. 
Powders three and four will only occasionally be required : but where the 
secretions of the intestinal canal are vitiated and the hepatic functions are im- 
perfectly performed, they, or some of the more active aperients (with occasional 
alteratives), will be efficient remedies, if judiciously and sparingly exhibited. 
7 



94 FORMULA OF REMEDIES. 

i 

Form 5. — Pilulse Colocynth. Comp. 

R. Extr. Colocynth. C. Pil. RheiComp. Pil. Cambogise C. aa 9i. Olei 
Cassiee gtt. vj. M. ft. Pilulse xij. 
Take one or two pills at bed-time every night, or every other night, or 

R. Pil. Colocynth. C. Pil. Galbani C. aa 3ss. M. ft. Pilul. xij. 
Take two pills twice a-day. 

Form 6. — Pilulse Jlperientes. 

R. Pil. Cambogise C. gr. xxx. Sodse Carb. Gluinse Disulph. aa gr. xv. 
01. Menth. Pip. gtt. vj. Syr. qs. M. ft. Pilulse xij. 
Take two or three pills at bed-time. 

Form 7. — Pilulse Jlperientes Jllterativse. 

R. Pil. Hydr. 9i. Hydr. Chlorid. gr. x. Pulv. Antimon. gr. x. Anti- 
mon. Tartarizat. gr. iij. Pil. Rhei C. S)i. Syr. qs. M. ft. Piiulse xij. 

Take two pills every other night. 

Form 8. — Pilulse Jlperientes Alterativse, 

R. Pil. Hydr. Chlorid. Comp. $1. Pil. Aloes cum Myrrha £ij. Extr. 
Sarsce. Extr. Taraxaci aa gr. x. Syr. qs. M. ft. Pilulse xvj. 

Take two or three twice a-day. 

Form 9. — Mist. Purgans Communis. 

R. Pulv. Rhei Magnes. Carb. aa gij. Conf. Arom. giss. Infus. Rhei 
Aquae Cinnamomi aa ^iij. M. ft. Mist. 
Take a wine-glassful early in the morning, two or three times a-week. 

Form 10. — Mist. Rhei Comp. 

From Guy's Pharmacopoeia. • 

R. Rhei pulv. gj. Sodae Carb. 3ij. Pulv. Calumbae gij. Aquae Menth. 
Pip. Aquse fontis aa gvj. M. ft. Mist. 
Take two tablespoonfuls three times a-day. 

STOMACHICS AND TONICS. 

It has already been observed that the various preparations of iron, 
several of which I annex, are by far the most valuable in these af- 
fections, but they cannot always be administered. If the digestive or- 
gans are much deranged, or if there be a proneness to diarrhoea, they 
will probably still more irritate the intestinal mucous membrane. Pre- 
liminary and cautious directions about the diet and the alvine secre- 
tions will be required, and when the tone of these organs is restored, 
and not till then, iron in some of its forms may be efficiently employed. 



FORMULiE OF REMEDIES. 95 

Occasionally, when the general health has been long disordered and 
tympanitis has ensued, other remedial combinations will be required. 

Form 11. — Pilulse Ferri Jlmmon. 

R. Ferri Amnion. >}ij. 

Extr. Gent. C. Extr. Papav. Alb. aa gr, x. 
Theriaci, qs. Ft. Pilulse xij. 
Take two pills three times a-day. 

Form 12. — Pilulse. Ferri cum Gentiand. 

From Guy's Pharmacopoeia. 

R. Ferri Sulphatis gr. i. Extracti Gentianae Mollioris gr. iij. M. ft. 
Pilula. 

Take one pill three times daily. 

Form 13. — Pilulse Ferri cum Quinse Disulphate. 

R. Ferri Sesquioxydi Gluinae Disulphatis a,a ^i. Extr. Gentianae Mol- 
lioris Extr. Papav. Alb. aa gr. x. 01. Cassiae gtt. vj. M. ft. Pilulse xij. 

Take two pills twice or three times a-day. 

Form 14. — Pilulse Ferri cum Galbano. 

R. Ferri Sesquioxydi, Pilularum Galbani Compositarum, aa. gr. xxv. 
Extr. Humuli. gr. x. 01. Cinnamom. gtt. viij. Theriaci qs. Ft. Pilu- 
lae xij. 

Take two pills twice or three times a-day. 

Form 15. — Pilulse Ferri cum Myrrha. 

R. Ferri Sesquioxydi, gr. ij. 

Pulv. Gummi Myrrhae, gr. iij. 
Theriaci qs. ut fiat Pilula. 

Take two pills three times a-day. 



TONICS WITH PURGATIVES. 

Form 16. — Pilulse Moes cumFerro. 

R. Ferri Sesquioxydi gr. i. Extracti Aloes Aquosi. Extracti Gentianse 
Mollioris aa gr. ij. 01. Menthse Piperitae gtt. i. ut fiat Pilula. 
Take two pills twice or three times a-day. 

Form 17. — Pilulse Colocynthidis cum Ferro. 

R. Ferri Sesquiostydi gr. xviij. Pilularum Galbani Compositarum Ex- 
tracti Colocynthidis Compositi aa 9i. Theriaci qs. ut fiant Pilulaa xij. 
Take two pills once, twice, or more frequently during the day. 



96 FORMULA OF REMEDIES. 

Form 18. — Pilulse Rhei cum Ferro. 

£. Pilularum Rhei Compositarum di]. 
Ferri Sesquioxydi 3i. 
Theriaci qs. ut riant Pilulse xij. 
Take two pills once, twice, or more frequently during the day. 

Form 19. — Pilulse Zinci Compositse. 

R. Zinci Sulphatis gr. xij. Extracti Gentians 3j. Ol. Anthemidis gtt. 
vj. ut fiant Pilulae xij. 
Take two pills once, twice, or more frequently during the day. 

Form 20. — Mistura Ferri Jiperiens. No. 1. 

R. Ferri Sesquioxydi gr. x. Magnesise Sulphatis. Sodse Sulphatis aa 
giv. Aquae destillatae gvj. M. ft. Mistura. 
Take two tablespoonfuls twice or three times daily. 

Form 21. — Mist. Ferri Jiperiens. No. 2. 

R. Ferri Sulphatis gr. x. 
Magnes. Sulph. giij. 
Acid. Sulph. dil. gj. 
Infus. Gent. Comp. Infus. Rosse Comp. aa. giv. M. ft. Mist. 

Take two tablespoonfuls twice or three times daily. 

Form 22. — Mist. Ferri Muriatis. 

R. Infus. Gentianse Compositi ^vij. 
Syr. Aurantii gviij. 
Tinct. Ferri Muriatis 1*1 xl. M. ft. Mistura. 

Take two tablespoonfuls twice or three times daily. 

Form 23. — Mist. Quinse Disulphatis. 

R. Infus. Rosae Compositi jfv. 
Tinct. Cardamomi Comp. 3j. 
Quinse Disulphatis 9j. 
Acid. Sulph. dil. nix. M. ft. Mistura. 

Take one or two tablespoonfuls twice or three times daily. 

Form 24.. — Mist. Ferri Iodidi. 

R. Ferri Iodidi gr. xviij. Tinct. Calumbse gj. Aqua? destillatas ^vij. 
M. ft. Mistura. 

Take one or two tablespoonfuls, two or three times daily. Apiece of iron 
wire should be kept in the phial, to prevent decomposition of the iodide of 
iron and precipitation of the sesquioxyde of iron. 



FORMULA OF REMEDIES. 97 



CORDIALS, ANTISPASMODICS, AND NARCOTICS. 

Form 25. — Mist. Ammonise, Composita. 

R. Ammoniae Carbonatis ^iss. Tinct. Castorei Sp. Lavandulae Comp. 
aa 5yj. Tinct. Hyoscyami gi. vel Syrupi Papav. Alb. giv. vel 
Morphiae Acetatis gr. | vel j. Aquas Menthae Piperitse ^vj. M. ft. 
Mist. 

Take one tablespoonful three or four times daily. It may be unnecessary 
to add any of the narcotic ingredients. 

Form 26. — Mistura Castorei Composita. 

R. Tinct. Castorei, %]. Sp. Lavandulae Comp. giv. Tinct. Camph. C. 
3iv. M. ft. Mistura. 

Take half a teaspoonful every three or four hours in a tablespoonful of 
water. 

Form 27. — Mistura Morphias Acetatis. 

R. Morphiae Acetatis gr. i. vel ij. 
Acid Acetici gtt. x. 
Aquae distillates giij. 
Tinct. Card. sp. M. ft. Mistura. 

Take five or ten drops occasionally ; frequently, if pain or spasm be urgent. 

Form 28. — Mistura Vini. 

From Guy's Pharmacopoeia. 

R. Vini Albi, vel Rubri, vel Spiritus Gallici ^vj. Ovorum Duorum Vi 
tellos. Sacchari ^ss. Olei Cinnamomi guttas iij. M. ft. Mistura. 

Take two tablespoonfuls frequently during the day, if there be languor or 
faintness from debility. 

Form 29. — Mistura Cretss Opiata. 

From Guy's Pharmacopoeia. 

R. Pulveris Cretae Comp. cum Opio. 3iij. Aquae Menth. Pip. gix. M. 
ft. Mistura. 

Take two tablespoonfuls after every liquid motion. 

Form 30. — Julepum Potasssz Carbonatis. 

From Guy's Pharmacopoeia. 

oris Potassae Carbonatis ^j. Aquae Menth. Viridis Exi. M. ft. 
Mistura. 

Take one or two tablespoonfuls in barley-water or linseed tea, twice or 
three times daily. 



98 FORMULA OF REMEDIES. 

Form 31. — Infusum Serpeniarix Compositum. 

From Guy's Pharmacopoeia. 

- R. Serpentariae C0ntus.C0ntrajervaeC0ntus.aa3v. Aquae Ferventis 
^xvj. Post Maceration, in vase leviter clauso per duas horas, liquo- 
rem cola, et adde Tinct. Serpentar. i§ij. M. ft. Mistura. 

Take three tablespoonfuls every four or six hours, occasionally adding to 
each dose if it be required, 

Liquor Ammon. Acet. %iv. vel 

Liq. Ammon. Sesquicarbonatis tt^ xxx. 

Form 32. — Pilula Moschi Composita. 

R. Moschi gr. xl. Pulv. Zingib. Pulv. Valerian, aa gr. vj. Camphor, 
gr. xij. Conserv. Rosae q. s. M. ft. pilul. xij. 
Take two pills every three or four hours. 

Form 33. — Pilula Sedativa. 

R. Pulv. Opii. gr. \. Camphor, gr. iv. Cons. Rosar. q. s. M. ft. pilula. 
Take one pill every four or six hours. 



NARCOTIC INJECTIONS AND SUPPOSITORIES. 

Form 34. — Enema Jintispasmodicum. 

R. Liq. Opii. sedativ. Tt^ xxx. Infus. Valerian, ^i. Mucil. Acac. 
^ss. M. ft. Enema. 
The injection to be passed into the bowel by a syringe night and morning. 

Form 35. — Enema Contra Spasmas. 

From Dr. Copland. 

R. Camphor. Rasae gr. v. — x. Potass. Nitratis gijl Olei Olivae §j. 
Tere simul, et adde Infus. Valerian. Decocti Malvae. C. aa j§v. 
M. ft. Enema. 

Form 36. — Enema Emolliens. 

From Dr. Copland. 

R. Flor. Anthemidis, Semin. Lini. Contus. aa ^ss. Aquae fervid, jfvj. 
Macera et cola ; dein. adde Opii. gr. ij. iij. vel vj. 
Half this quantity to be used at a time. 






FORMULA OF REMEDIES. 99 

Form 37. — Enema Belladonna. 

From Dr. Copland. 

R. Fol. Belladonnas Exsic. gr. xij. Aquas Fervid. 5 vj. M. ft. Enema. 

In severe dysmenorrhea, in retention of urine from spasm of the sphincter 
vesicae, or spasm of the rectum. 

Form 38. — Enema Olei Terebinthinse. 

From Guy's Pharmacopoeia. 

R. Olei Terebinth, £ss. Ovi. unius Vitellum. Tere simul, et gradatim. 
adde Decocti Hordei tepid ^x. 
To be used once a-day or more frequently. 

Form 39. — Enema Saponis Compositum. 

R. Saponis Mollis !§j. Pulv. Opii. gr. iij. vel. vj. Aquae Ferventis ^vj. 
M. ft. Enema. 

Half or the whole quantity to be used once, twice, or three times daily. 

t 
Form 40. — Enema Tabaci. 

From Guy's Pharmacopoeia. 

R . Tabaci 3j . Aquas Ferventis ^ xvj . Macera per sextam horae partem 
et cola. 

One-quarter or half the quantity maybe used, and if necessary the injection 
may be repeated in an hour. 

Form 41. — Suppositorium Opii. 

R. Pulv. Opii. gr. \ vel i. Sapon. Castiliensis gr. iij. M. ft. sup- 
positorium. 

The suppository to be used once, twice, or thrice daily. 

Form 42. — Suppositorium Belladonnse. 

R. Extr. Belladonnas gr. i. vel. ij. Saponis Castiliensis gr. iv. vel iij. 
ft. suppositorium. 

To be used once or twice a-day. 

emmenagogues. 

Form 43. 

R. Liq. Ammon. fort. 5L vel 3;iss. 

Lactis tepid ^xvj. M. ft. Injectio vaginalis. 
A third part to be passed into the vagina three times daily. 



t 



100 FORMULAE OP REMEDIES. 

Form 44. 

From Dr. Schonlein. 

R. Aloes Socotorin. gr. x. Mucilaginis Acacia? %]. M. ft. Injectio 
intestinalis. 
The injection to be thrown into the rectum two or three times a-day. 

Form 45. 

g. Sinapis pulveris gij. 

Aquse Ferventis §xvj, M. ft. Injectio. 
A third part to be passed into the vagina three times daily. 



I 



CHAPTER VI. 

OF MENORRHAGIA, 

Definition. — Inordinate Menstruation, both as to the frequency of re- 
turn, and the amount of the secretion ; in the majority of instances accom- 
panied by direct loss from the uterine arteries. 

There are two forms of the disease. 

First, Profuse Menstruation, either as to frequency of return, or the 
amount of the secretion, or both, without uterine bleeding. 

Second, Profuse menstruation accompanied by direct loss of blood 
from the uterine arteries, including three varieties. 

a. Acute or active menorrhagia ; occurring in the plethoric and ro- 
bust. 

b. Passive or chronic menorrhagia ; the subjects of this variety being 
the delicate, hysterical, and exhausted females; and, f 

c. Congestive menorrhagia ; generally met with at the middle or 
more advanced periods of life. 

Profuse menstruation, either as to frequency of return or the amount of 
the secretion, or both, without uterine bleeding. 

RistGry and Symptoms. — I may at once observe, that the hemor- 
rhages of abortion, pregnancy, and parturition, and of the various or- 
ganic diseases of the uterus, do not come within the scope of this 
chapter : and to avoid a perplexing multiplication of names, I include 
profuse secretion of the catamenia as a form of menorrhagia, as it is 
rarely a disease of long continuance, unaccompanied by bleeding di- 
rectly from the uterine vessels. If we reflect on the large supply of 
blood constantly furnished to the uterus during the greater part of life, 
and which is every month, for a functional purpose, still further aug- 
mented, it is not at all surprising that the limits of secretion are occa- 
sionally exceeded, and that, instead of a fluid only partially sanguine- 
ous, its usual product, pure blood, should be discharged from its vessels. 
Thus, so long as the discharge, even if it be profuse, is not blood, men- 
struation only exists ; but if the secretory function is either altogether 
or only partially superseded from excessive determination to the uterine 
vessels, their orifices may give way, and, as then they will permit blood 
to pass unchanged, menorrhagia is established. 

Profuse menstruation and menorrhagia are neither confined to one 
class of females nor to one age. The young are less liable than those 
more advanced in life. The plethoric and robust less frequently than 
females of susceptible and feeble constitutions. Still, circumstances 
may induce these diseases in every class, the periods of reproduction 
and catamenial cessation being more obnoxious to them than all others 
— climate and peculiarity of system being criteria of importance. In 



t 



102 MENORRHAGIA. 

northern and cold countries, the amount of menstrual secretion which 
is only natural here, would be regarded as excessive ; and in hotter cli- 
mates, what we consider profuse menstruation, would be strictly nor- 
mal. In one individual, or in the female branches of a whole family, 
five, six, or seven ounces may be only a healthy amount of discharge, 
while in others such a quantity would be morbidly profuse. It follows 
then, that in the one case, health not weakness would accrue, while in 
the other, weakness not health would be the result. 

The question, therefore, whether menstruation be healthy or inordi- 
nately profuse, will mainly depend on climate and idiosyncrasy, and 
especially on its constitutional effects. If it occur during pregnancy 
and lactation, it is unnatural and in excess ; and on several occasions, 
in married women more especially, I have known it recur after long 
periods of suspension, so profusely as to have been mistaken for abor- 
tion. The way in which profuse menstruation comes on is various. I 
have now a patient in whom, for some months, the discharge, without 
any admixture of coagula, has every second week set in suddenly and 
with a large gush ; this discharge, with an interval of only a few hours, 
being repeated for four, five, or six days. This individual is thirty-one 
years old, and unmarried ; and so far as I can ascertain, is without the 
slightest evidence of structural disease ; but she is anemiated and fee- 
ble. More frequently, however, the secretion is excessive from its con- 
tinuance, lasting ten or twelve days, or is too early in its return. 
Young and single women are more prone to the latter, while married 
females, weakened by childbirth, undue lactation, and leucorrhcea, 
are obnoxious to the former variety. Leucorrhcea, indeed, has much 
to do with profuse menstruation, and is generally present, either in the 
catamenial intervals, or has existed prior to the excessive menstruation. 
Dewees states that in America he has scarcely ever known a case of 
genuine profuse menstruation. Such examples being almost invariably 
accompanied by the discharge of pure blood. I do not doubt the accu- 
racy of this statement ; but a similar statement of this country $ and of 
my own experience, would not be correct, as instances, and not a few, 
have come under my own observation. 

The symptoms are precisely those induced by a drain on the sangui- 
neous system, varying in degree, according to the amount, the continu- 
ance, and the more or less frequent recurrence of the discharge. At 
first languor, inactivity, and sensations of weakness, rather than pain 
across the loins, are complained of; subsequently there is severe and 
almost constant aching in the back and lumbar region, coming round 
to the hips and front of the thighs, and to the lowest part of the 
abdomen. The face is pale, sometimes bleached and cadaverous. 
The patient suffers from nervous headache, the pain being often con- 
fined to one spot, tinnitus aurium, throbbing of the temples, frequent 
vertigo, and where the loss has been excessive, a sensation as though 
a clock were ticking in the head. The heart acts feebly on small 
quantities of blood, and there is in consequence chilliness of the surface 
and coldness both of the hands and feet. If the malady continue, and 
particularly if there be much leucorrhcea, the whole series of symptoms 
now described becomes more distressing. The disordered state of the 



i 



MENORRHAGIA. 103 

brain, from a diminished supply of blood, sometimes closely resembles 
that arising from repletion. From ignorance or a disregard of this 
fact, giddiness, confusion, and a sensation of falling from sudden move- 
ments, in turning or lifting the head, have excited a fear of apoplexy, 
and the bleeding and antiphlogistic treatment which have been prac- 
tised, have insured a still further aggravation of the original disease. 
Nor will the more serious indications dependent on excessive cata- 
menial discharge, be confined to the brain alone. The lumbar and 
central pains become more decided, the headaches more agonising, 
the derangement of the stomach and bowels is permanently increased, 
and there is almost constant pain, felt in some part of the course of 
the colon, affecting either the sides or centre of the abdomen. There 
is palpitation, and all the symptoms so graphically described by Dr. 
Addison. Occasionally, in some of the worst examples, there is con- 
firmed diarrhoea. I have many times seen oedema, and in one case, 
where the patient had long resided in the East Indies, and was much 
exhausted by frequent abortions, there was general anasarca. Nervous- 
ness almost to insanity, melancholy, and, according to some authors, 
epilepsy have resulted from the disease. So far as my observation 
has gone, a vaginal examination has revealed nothing beyond a soft, 
flabby condition of the vagina and uterus, leucorrhoea, and an os 
slightly more patulous than natural, but without tenderness or indu- 
ration. The consequences of profuse menstruation, if protracted, are 
almost sufficiently evident from the detail of the symptoms. Dr. 
Marshall Hall, in his " Essay on Bloodletting and its evils," has fully 
explained them. I may, however, remark that they are precisely of 
the same character as are produced by hemorrhage from any other 
part. Of course the probability of early cure will greatly depend on 
the severity and repetition of the attack. In the slighter cases little 
treatment is required, and the disease often subsides almost sponta- 
neously ; and even in the>more aggravated examples, suitable and per- 
severing treatment generally avails. A greater proneness to abortion, 
if the patient become pregnant, and a disposition to prolapse of the 
uterus and vagina, are results of the malady. 

Causes. — Delicacy and debility of system and undue plethora con- 
duce to the disease. The former frequently ; the latter only in few 
instances. In all classes these causes may be brought into activity by 
cold, inordinate physical effort and mental excitement. In married 
women, repeated labours and abortions, and undue suckling, lay a 
foundation for the malady. In all, excessive use of the genital organs 
may lead to this or any other form of menorrhagia, and the disease has 
often had its origin in hemorrhage occurring after labour. 

Diagnosis. — It is by no means difficult to distinguish this from the 
other forms of menorrhagia by the absence of coagula. If the discharge 
does not clot, it is still menstrual secretion ; if, on the contrary, like 
blood lost from other parts of the body, it separates into serum 'and 
crassamentum, it is no longer a case of simple catamenial excess. The 
freedom of the patient from organic uterine disease will be satisfactorily 
ascertained by a vaginal examination. 

Treatment. — This will vary in females of different constitution, and 
in all there will be a marked distinction between the measures adopted 



104 MENORRHAGIA. 

during the discharge itself, and in the menstrual intervals. In plethoric 
and robust individuals, the larger amount of secretion is often salutary, 
and may be allowed to continue in many instances till it naturally sub- 
sides. Where treatment is necessary, moderate venesection may, a few 
days before the expected period, be practised ; more frequently local 
depletion, by cupping on the loins, or leeches to the pudendum or peri- 
neum, and in some instances to the cervix uteri. When the loss is 
really excessive, the patient should be confined to the sofa or a mat- 
tress, strictly maintaining the recumbent posture, and the diet should 
be unstimulating and cold. Saline purgatives, with dilute acid and 
nitre, may always be exhibited ; more rarely digitalis and superacetate 
of lead (vide formulae). The apartment should be cool, the patient 
being lightly covered by bed-clothes, and excitement of every kind 
must be carefully avoided. In some severe cases it may be necessary 
to apply cold locally : iced water, and ice itself, wrapped in bladders, 
are used with this view. It has been thought right to inject cold stimu- 
lating fluids into the vagina, and, in a very few examples, even into 
the uterus, and to plug this canal as far as the os. I do not say that 
such extreme measures are never demanded, but happily, if judicious 
treatment be early adopted, they will rarely be required. 

In the interval of menstruation, a spare, unstimulating, and only mo- 
derately nutritious diet, and frequent saline aperients, should be enjoined. 
"Where there is decided plethora, shown by a red and flushed counte- 
nance, swimming in the head, and a full, hard, and quick pulse, small 
and repeated bleedings are beneficial. Daily exercise by walking or 
riding, although the former is to be preferred, and the avoidance of 
heated apartments and luxurious indulgences, will contribute to a 
healthier state of the system generally, and particularly of the uterus. 

In delicate, pallid, and feeble patients, the disease must be treated 
differently. Here the excess of secretion, so far from being salutary, 
as it occasionally is in the plethoric and robust, is decidedly injurious, 
every return, by weakening the uterine capillaries, aggravating the 
anemia. Instead of depletion and antiphlogistic means, ammonia and 
small doses of the acetate of morphia, and the mistura vini of Guy's 
Pharmacopoeia, are to be employed ; and where the loss is large, no 
remedy will generally be more efficient in checking it, and in shorten- 
ing the period of the flow, than the ergot. It may be given either in 
powder or tincture ; of the former, five grains, and of the tincture, 
thirty drops every six or eight hours. Cold applications, and astringent 
injections (vide formulas) into the vagina, have been already men- 
tioned. Dewees recommends, for this purpose, sugar of lead and lau- 
danum, and speaks highly of elixir of vitriol and laxatives. Mackin- 
tosh enjoins the use of an enema, containing a scruple of the sugar of 
lead. All the remedies are intended, either by lessening the activity 
of the general circulation, or by securing the contraction of the uterus, 
to diminish the quantity of blood sent to it, and thus to curtail the 
amount of secretion. 

In the interval such measures must be employed as shall preclude the 
return of the malady. If it can be attributed to over-lactation, ex- 
cessive leucorrhoea, or frequent abortion, the child should be weaned, 
the leucorrhoea cured, and the risk of pregnancy for a time prevented 



MENORRHAGIA. 105 

by abstinence from intercourse. Chalybeate water, and mineral tonics, 
a residence by the sea, or at some of the various spas in this country 
or abroad, salt-water baths, of any kind most agreeable to the patient, 
vaginal injections, sponging with cold salt water all over the loins and 
hypogastric region, are well calculated to relieve local weakness and 
to aid the more direct and powerful measures. 

Second, Profuse Menstruation, accompanied by discharges of blood di- 
rectly from the uterine vessels, including three varieties. 

a. Acute or active menorrhagia ; occurring principally in the plethoric 
and robust. 

History and Symptoms. — This form of the disease is much less com- 
mon than the passive and congestive varieties. It occurs most fre- 
quently in plethoric married women who live generously, and in whom 
the circulation is active. In such individuals exposure to cold or wet 
during menstruation, or any circumstance deranging their health, may 
induce fever, inordinate action of the heart, congestion and subsequent 
rupture of the uterine capillaries, and menorrhagia. I have also oc- 
casionally seen inflammatory and spasmodic menorrhagia, in young, 
florid, and robust unmarried girls: although these varieties are really 
more rare than the others, I believe they often exist unnoticed. The 
undue plethora, on which they mainly depend, is relieved by this larger 
periodical loss, and if it do not occur too often, this morbid state may 
be altogether cured by it. In healthy women also, a profuse cata- 
menial discharge, even when it is attended by pain, is often long dis- 
regarded, such an event being generally viewed in a favourable light. 
It is not, therefore, till the loss is really excessive and somewhat alarm- 
ing, or till it has induced marked debility and a pale, wan countenance, 
that medical aid is sought. In active menorrhagia there generally 
exist, immediately before the expected period, and occasionally for a 
few days prior to the flow, considerable tension and fulness within the 
pelvis, accompanied by a feeling of weight and throbbing in the uterus 
itself. The mammse often sympathize, becoming tumid, hot and tender 
on pressure, and the external genitals are sometimes slightly swollen 
and painful. The pulse is quickened, there is oppression of the head, 
and often decided headache, with sympathetic fever. In this way the 
acute or active form of menorrhagia is ushered in and is throughout 
characterized by a predominance of inflammatory or spasmodic symp- 
toms, or by a combination of both. Where inflammation is present, 
there will be fixed pain in the uterine region ; a hot dry skin, and a fre- 
quent, hard and full pulse. Where spasm prevails, the pain will not be 
constant ; but having continued a longer or shorter time, and often most 
severely, it will subside, and, after an interval, again recur with throes 
resembling the pains of labour. The discharge, too, is equally variable, 
ceasing for short periods, during the pain, and returning when it sub- 
sides. The pulse, during the spasm, is contracted, irritable, and quick ; 
afterwards it becomes softer and slower, giving proof, by this rapid 
change, of a state of system, neither of inflammation nor debility, but 
of irritation. The progress, duration, and severity of these attacks 
are extremely variable. Sometimes the discharge comes on and con- 
tinues by gushes, and numerous coagula are expelled. The patient, in 
many instances, is thus relieved; the headache, tension, and pain in 



106 MENORRHAGIA. 

the uterine region are quickly diminished : the pulse is softer and less 
quick: the skin cooler and moist; and the remainder of the period is 
passed over with tolerable comfort. In the more protracted and ag- 
gravated cases, the discharge often continues for three, four, five, or 
six days, not without diminution, but still with such a proneness to ex- 
cessive return, that the patient is compelled to avoid exertion, and to 
maintain, almost constantly, the recumbent position. On the subsi- 
dence of the flow, she is weak and exhausted, and several days elapse 
before she regains her usual freshness of countenance and strength of 
pulse. It is easy to mark the transition from this to the passive form 
of monorrhagia ; for although, at first, the recurrence of the events 
just now described may not seriously impair the health, yet after a 
time, the loss produces a marked impression on the system ; the flow 
lasting longer, and the number of days between the catamenial pe- 
riods being so diminished, that scarcely is one attack over, before 
another approaches. Thus the active and acute variety is merged in 
the passive form of the disease. 

Causes.— From the history already given, it will be inferred that 
menorrhagia is generally dependent on morbid conditions of the con- 
stitution ; although its causes may be accidental or local. Thus, 
while the active form is mainly associated with a plethoric habit, and 
does, under such circumstances, afford relief, it may still be frequently 
traced to morbid uterine activity and excitement, arising from local 
injuries, such as blows or falls, sexual excesses, repeated abortions 
and leucorrhcea; irritation of the bladder and of the intestines gene- 
rally, and especially of the rectum, from hardened fa?ces, hemorrhoids, 
worms, tenesmic purging, constant and even occasional constipation. 
Doubtless such causes will be rendered additionally injurious by too 
protracted and severe mental and physical efforts, rich living, heated 
apartments and soft beds, indolence and too much sleep. 

Diagnosis.— The distinction between the active and inflammatory 
or spasmodic menorrhagia, and the passive form of the disease, is not 
always easily made. In the beginning there is little difficulty ; but 
when, from frequent repetition, debility exists, we may err. Still the 
countenance, the pulse, and the " tout ensemble" of the_ patient are 
such that we shall not remain long in doubt. Nor must it be forgot- 
ten, that on a correct discrimination of these different conditions, the 
success of the treatment will greatly depend. It is true that active 
menorrhagia may coexist with debility, the uterine vascularity and 
circulation being, from local causes, morbidly increased ; but it would 
be a great mistake to treat this latter condition as we should that form 
of the malady where the. discharge was dependent on general fulness 
and activity. If to aid the diagnosis the uterus be examined per va- 
ginam, there will rarely be discovered any marked change in its volume 
or position, although I have noticed some fulness and heat about the 
cervix and body of the organ. 

Treatment. — This is scarcely different from what has been already 
enjoined in profuse menstruation, occurring in plethoric individuals, 
vide page 104. But I may remark, that the employment of smart 
drastic purges (vide formulae), often does great good. The late Dr. 



MENORRHAGIA. 107 

Cholmeley, of Guy's, relied almost exclusively on their exhibition ; and 
he has frequently, as he passed through the wards, pointed out cases 
entirely cured by these alone. 

In spasmodic Menorrhagia, to which I have already referred, the pulse 
is irritable and quick, not hard and full. The system is not plethoric, 
nor the pain constant (vide cases), but it subsides and again recurs. 
Here bleeding, nitre, and digitalis, fail to relieve ; and recourse must 
be had to anti-spasmodics, anodynes, and occasionally to alteratives. 
It is not always easy at once to distinguish this form ; but if antiphlo- 
gistic means have been tried unsuccessfully, the patient will often be 
cured by remedies of a different class. Dr. Gooch says, " that a lady 
labouring under spasmodic menorrhagia, went through the whole rou- 
tine of antiphlogistic treatment without any benefit. I then gave her, 
he adds, one grain of ipecacuanha every hour; in eight hours she 
became nauseated and sick, and the discharge immediately ceased. 
This state of nausea was kept up for a day or two, and the dis- 
charge did not recur. When you have a case of menorrhagia, at- 
tended with a quick and irritable pulse, the pain subsiding and recur- 
ring, you may be certain that it arises from spasm or irritation, and that 
it w T ill be relieved by anti-spasmodic remedies. The two best are ipe- 
cacuanha taken into the stomach, and assafcetida, with opium injected 
into the rectum. A grain of ipecacuanha is to be taken every hour till 
nausea is produced ; which state must be maintained for a day or two, 
by repeating the same dose as frequently as may suffice for this pur- 
pose ; and quiet local irritation in the uterus by injections of assafcetida 
and opium, by the enema antispasmodicum, form 34, 35, 36, 37, or 39, 
to be found at pages 98 and 99. There is a very marked connexion 
between the pain and the discharge ; for if you can relieve the one, the 
other wdl cease." 

Nor must the treatment in the interval be disregarded ; in profuse 
menstruation, unattended by real uterine hemorrhage, allusion has 
been pointedly made to its extreme importance. If the bleeding and 
the antiphlogistic regimen, practised as a period approaches, be ex- 
changed, after the disease subsides, for nutritious diet and wine, the 
malady will not only continue, but it will become aggravated, and the 
loss, during menstruation, may be so large as to excite considerable 
apprehension. Many patients protract the menorrhagia by such error, 
and, by repeated discharges, the passive form is induced. A nice 
distinction is necessary here : thus, several times when I have thought 
that the loss has depended on debility, and I have unsuccessfully exhi- 
bited the ergot and tonics, I have gone back to the antiphlogistic plan, 
and have cured the patient. Nor let it be forgotten, that local deple- 
tion is sometimes most beneficial ; especially in those cases where, in 
the absence of general plethora, there is local uterine fulness. 

b. Passive or chronic menorrhagia ; the subjects of this variety being 
the delicate, hysterical, and exhausted females. 

History and Symptoms. — This is the most common form of r^nor- 
rhagia, and approaches in frequency to chlorosis and amenorr 1 ^^ A 
partial explanation may be found in the want of attent^ n }° earJy 
menstrual profusion, and in the too indiscriminate u c Wlne and 



108 MENORRHAGIA, 

other stimulants. The various degrees in which it exists, deserves 
notice. In some the excess may be so slight, as hardly to produce 
any morbid effect ; and from this stage onward, to examples of marked 
hemorrhagic prostration, every shade of the complaint may be wit- 
nessed. I have in my recollection several instances where a fatal re- 
sult seemed highly probable. An additional reason is thus supplied for 
careful investigation, prior to and during the treatment, by tonics and 
wine ; and where such measures are determined on, their use must be 
watched, modified, and occasionally suspended. An attack of fever, 
or uterine congestion, will demonstrate the propriety of this admoni- 
tion, and prove that the management should rest on principle, and that 
it must not be pursued merely as a matter of routine. 

I need scarcely mention the class of women most liable to passive 
menorrhagia — those originally delicate, or who have become so from 
any of the causes already enumerated at the commencement of this 
chapter, and not the robust and plethoric, are its subjects. 

The symptoms are precisely those of morbidly profuse menstruation, 
fully pointed out at page 102. 

Causes. — The same as in profuse menstruation. 

Diagnosis. — The presence of clots in the discharge, or the stiffening 
of the linen by its flow, sufficiently explain the character of the disease. 
If the uterus be examined, it will rarely be found increased in size ; 
but its cervix and os, as well as the vagina, are generally soft, the 
former having lost its close, welted feel, and the whole being bathed 
in leucorrhoeal discharge. Such an inquiry will also reveal any 
structural lesion of these parts, should it exist. 

Prognosis. — It may perhaps be unnecessary to say much on this 
point, as a fatal result is exceedingly rare ; but, as the long continuance 
of the malady may induce dropsies of various cavities, and may call 
into play morbid tendencies about other organs, a too confident opinion 
should not be given. Our anticipations of cure should spring not only 
from the tractable character of the malady, but from a conviction that 
the patient will strictly and perseveringly carry out our measures of 
relief. 

Treatment. — Reference must be made to page 104, where the means 
generally successful in arresting excessive menstrual flow are enume- 
rated. Rest in the recumbent posture, during and previously to the 
attack, either in bed, on a mattress, or on the sofa, is indispensable. 
Without it the best-devised treatment will fail. At first, patients dis- 
regard the injunction ; but the continuance of the discharge, increasing 
debility, and the attendant evils, compel obedience. Astringent injec- 
tions should rarely be used during the first few days of the menstrual 
period, as they often produce uterine spasm ; but when coagula are 
passed, either alone or mixed with the catamenial fluid, the secretory 
function is either partially or entirely suspended, and injections may 
the^ be highly beneficial. (Vide formulae.) Some patients derive little 
or no advantage from them — others use them so partially, as to pre- 
clude arij probability of benefit — while not a few ascribe pain, an un- 
usual symp^ m j n p ass i ve menorrhagia, and increased discharge, to 
their exhibition- j t - s essent i a } t h at tne parent lie, when the injection 



MENORRHAGIA. 109 

is thrown into the vagina, that the pelvis be raised by placing a sofa- 
cushion under the hips, so that the fluid may easily reach the upper 
extremity of this canal, and that whatever quantity be injected, it shall 
be retained for ten or fifteen minutes in direct apposition w T ith the 
parts. To effect this, the nurse should make firm pressure on the 
vaginal orifice by a napkin, accurately applied. Where these condi- 
tions are complied with, and where, occasionally, in susceptible and 
irritable women, the injections are slightly warmed, so as to prevent 
the probability of the occurrence of uterine spasm and pain, I know 
practically that great good will generally result from their adminis- 
tration. 

But life is occasionally well nigh destroyed by excessive menorrha- 
gic loss — the patient being reduced to the same state as by uterine 
hemorrhage after labour. If the practitioner has reason, from its pre- 
vious occurrence, to apprehend a renewed visitation of this kind, every 
preventive measure must be adopted. Not only must the treatment in 
the interval be carefully followed out, as directed at pages 104 and 
105, but absolute rest must be enjoined for several days prior to 
the expected catamenial return ; sexual excitement, physical exertion, 
stimuli likely to affect the vascular system and the uterus, and intes- 
tinal constipation, must all be carefully avoided. During the flow, if 
alarming loss of blood seem to be approaching, the ergot and opium 
(vide formulae), injections of cold water and astringent lotions into the 
rectum, and, above all, plugging the vagina, as far as the os, must be 
practised. Soft dry tow, slowly introduced in small quantities^ till the 
passage is entirely filled, forms the best tampon or plug, and it may be 
allowed to remain unchanged for twenty-four or thirty hours. The 
patient will probably object to such a remedy, and suffer slightly from 
its use ; but neither of these circumstances are sufficient to justify the 
practitioner in giving it up. A silk handkerchief, lint, or linen, may 
be used, but they must be dry. If wet or saturated w T ith moisture, 
their introduction is painful and difficult : dry soft tow, in small pieces, 
is certainly far better. I have seen two cases, where, if the apparatus 
for transfusion had been within reach, I should have used it. Both 
patients, however, gradually recovered. It may be urged, that injec- 
tions of cold or medicated water into the uterine cavity, would be 
important. I confess, without knowing that the mucous lining was 
healthy, the fear of subsequent inflammation would, with me y generally 
prevent their employment. I am, however, convinced that, in exces- 
sive menorrhagia, plugging is not sufficiently often resorted to. It need 
scarcely be enjoined, that if the patient is reduced to a very low ebb, 
or if there be prolonged and profound syncope, she must be moved with 
the greatest care. In the syncope following excessive puerperal bleed- 
ings, such precaution is all-important, as asphyxia might result from its 
non-observance. It is scarcely less necessary in the exhaustion pro- 
duced by excessive menorrhagia. 

c. Congestive Menorrhagia, generally, met with at the middle or more 
advanced periods of life. 

History and Symptoms, — On this form of the malady enough attention 
has not been bestowed. And yet, it differs so much from the others, 
S 



HQ MENORRHAGIA. 

that it is a matter of surprise that its peculiarities should have been 
only slightly noticed. It continues long, occasionally for several years 
(vide cases), and frequently in alarming excess. It is often preceded 
and followed by large watery and leucorrhceal discharges, and pain 
in the uterine and lumbar regions is a common accompaniment. Its 
sympathetic effects on the brain, lungs, and heart, are occasionally 
severe ; and, where the disease has continued long, there is generally 
coldness of hands and feet, a feeble and quick pulse, and an anxious, 
pallid and sunken countenance. The alterations in the size and feel 
of the uterus, which form a part of the disease, cannot, at this period 
of life, be recognised without some alarm. The malady is not confined 
to one class of women. The plethoric are not, as far as I know T , more 
prone to it than the debilitated and irritable. I have rarely, if ever, 
seen it, before thirty-eight or forty years of age ; but I have several 
times met with modified attacks, independently of organic complica- 
tions, after menstruation might have been supposed to have ceased. 

In the milder instances, the symptoms already described terminate, 
after a more or less protracted continuance, in the entire cessation of 
the function ; but in other and more protracted examples, the symptoms 
are so extreme as to excite real apprehension. The recurrence of 
the bleedings is uncertain, although in general, a catamenial period 
will be partially observed. Occasionally the loss continues for many 
weeks or months, without any complete cessation : the only apprecia- 
ble change consisting in a diminished flow, or the discharge becomes 
either aqueous or leucorrhceal, and perhaps slightly or offensively odo- 
rous. In many cases there will, at the expiration of a fortnight, or 
midway an the interval, be a peculiar bearing, acute pain in the lower 
part of the uterus. Several of my patients have noted this pain very 
accurately, and have correctly regarded it as indicative of a repetition 
of the menorrhagia. This symptom has occurred too often to allow 
me to doubt that it is in some way connected with the affection. Dr. 
Churchill mentions that in most, if not all the cases he has seen, there 
was considerable dysuria, and that, in several, it was necessary for the 
patient to He down before the bladder could be completely evacuated. 
Irritation about the neck of this viscus, extending along the urethra to 
its orifice, is common ; but the dysuria, especially to the extent related 
above, I have rarely met with. Nor must it be forgotten that after these 
morbid occurrences have repeatedly taken place, and w T hen every 
thought of pregnancy has been given up, conception has occurred. 
Such an event, for a time at least, and perhaps permanently, cures the 
affection. It is therefore important to bear in mind its possibility. I 
have known two examples of healthy pregnancy under these circum- 
stances, after an interval of five or six years from the former accouche- 
ments. Headache, embarrassed respiration, bleeding from the nose, 
sometimes excessive dyspepsia, impaired appetite, and emaciation, are 
frequent concomitants : after all, these various mischiefs may only be 
temporary. The function, on whose morbid condition they all depend, 
is itself wanting, and a few^ more months may secure its permanent sus- 
pension. Thus, sometimes, even with only domestic care, and often 
with proper medical treatment, the affection declines, and eventually 



MENORRHAGIA. Ill 

the patient regains more health than she has for a long time enjoyed. 
But this is not always so. Unhappily there are eases where the 
hemorrhages, and their attendant evils, continue for many months, even 
for several years, inducing a strong belief that organic disease must 
really exist ; nor must we forget that malignant changes do, although 
rarely, develope themselves. Even in their absence, life is, now and 
then, eventually destroyed by exhaustion, arising from the repeated 
bleedings, by phthisis, or by dropsies of some of the great serous cavi- 
ties. Anxious inquiry is directed to the probable time of final cessa- 
tion, and it is often asked, how long these bleedings may continue when 
they are not connected with structural disease ? In many instances, 
the function ceases at forty-four or five ; in more, at forty-seven, eight, 
or fifty ; in a few, at a much more advanced period, and in fewer 
still, at thirty or between thirty and forty years of age. I confess my 
inability to answer the latter question ; but 1 1 have met with more than 
several instances, where hemorrhages, alarming in degree, have 
continued for twelve, eighteen, twenty -four, and forty-eight months, 
and have ultimately declined, and the sufferer has regained good 
health. 

It is right in every protracted hemorrhage from the uterus to ex- 
amine. By this alone, and I allow that even then we frequently fail, 
can we expect to ascertain whether there be polypus, a sub-mucous 
tumour, or so much increased bulk as to render the existence of or- 
ganic lesion highly probable. In the majority of examples of conges- 
tive menorrhagia, I believe that increased uterine bulk, fulness of the 
cervix, and openness of the os, constitute the whole of the diseased 
change. 

Pathology. — Congestion of the uterine vessels is the explanatory 
cause of these bleedings. In some instances, there is an unusual and 
excessive accumulation of blood, and then it is not at all improbable 
that some of the branches of the uterine arteries, ramifying on the mu- 
cous membrane, give way. In sub-mucous tumour of the womb, these 
vessels are abnormally large, and are by their rupture the source of 
frequent hemorrhage. 

On the whole, the symptoms are indicative of slow progress, and 
lead to the conclusion that the disease is of the passive kind. The af- 
fection is probably dependent on the peculiarity of age — the period 
having arrived when this most important function is about to cease. 
I have already noticed its supposed frequent complication with organic 
disease: nor is it possible not to feel anxiety on this point when we 
remember that vessels and tissues in a state of nearly constant conges- 
tion, become hypertrophied, and liable to the invasion of structural 
and malignant change. 

Diagnosis. — It must not be forgotten that losses of blood occur in 
connexion with other states of the uterus than the various forms of 
menorrhagia. Approaching abortion is often supposed to be menor- 
rhagia ; nor is the mistake corrected, till the ovum is expelled, and the 
hemorrhage ceases. I lately saw a case, and it is unnecessary to 
mention the more common occurrences of this kind, where, from the 
emaciation, bleached countenance, and exhaustion, I had formed a 



;Q2 MENORRHAGIA. 

most unfavourable opinion, the flooding having continued, although 
not excessively, for nearly six months. On examination, 1 found the 
uterus large, and the lips* of the uterine aperture swollen, but not patu- 
lous. The idea of pregnancy as the patient was forty-four, and had 
borne children for several years, did not occur to me. I prescribed 
some medicine containing ergot, and I gave a doubtful opinion. After 
taking three doses, she expelled a blighted ovum, and in a few months 
entirely, although with difficulty, recovered her health. 

" I was called, " says Dr. Goocb, " in the earliest part of my prac- 
tice, to a lady who had for a considerable time a dropping from the 
uterus, which had produced a bleached, cadaverous countenance, cold 
hands and feet, and great debility. On examination, I found at the 
upper part of the vagina a little long projecting tumour, which I thought 
might possibly be a peculiar formation of the cervix uteri. I was af- 
terwards called in a great haste to see her, and, on my entering the bed- 
room, she said there w r as something coming away ; and, on examina- 
tion, I found the leg of a fcetus in the vagina. I speedily delivered her 
of a fcetus of about four months* growth ; the placenta soon followed, 
and the hemorrhage ceased. This was a blunder of mine ; for that 
which I supposed to be the cervix uteri, was no other than the foot of 
the fcetus, just beginning to protrude through the os tineas." 

The diagnosis of monorrhagia from pregnancy is important : but 
not so important, nor so difficult, as its distinction from some of the 
more concealed organic diseases. Corroding ulcer, cauliflower ex- 
crescence of the os, ulcerated carcinoma of the cervix and polypus, 
descended into the vagina, are easily made out by a common exami- 
nation; but whether protracted, frequently recurring, and dangerous 
hemorrhages arise from uterine congestion, or from sub-mucous tu- 
mour, a polypus yet retained in the uterine cavity, or from organic dis- 
ease of the mucous lining itself, is by no means easy. Often in the 
course of these hemorrhages, there is so much pain, such apparent 
traces of malignant disease about the face, so much emaciation, and 
such very trivial and temporary benefit from every remedy used, that 
in despair one believes, that it must be a malignant affection (vide 
case). After a time, however, and perhaps unexpectedly, the bleed- 
ings partially cease, the pain diminishes, and the patient's health is im- 
proved. A vaginal examination reveals nothing beyond what has been 
already mentioned, and hope is again encouraged. Thus a favoura- 
ble diagnosis will mainly depend on the healthiness of the uterus, so 
far as the finger can examine its structure; on the absence of progres- 
sive and marked emaciation ; on diminishing, at least not increasing, 
hemorrhages; on the general concurrence of the bleedings with the 
menstrual periods ; and on the lessened volume of the uterus during the 
menstrual intervals. Other circumstances, which cannot be accu- 
rately expressed, but which form a part of that unwritten and incom- 
municable tact, acquired by all observant men, will aid the judgment. 
A strumous constitution, glandular tumours in other parts, hard tu- 
mours of the fundus or body of the uterus, broad ligaments or ovaries, 
increasing hemorrhages and uterine pain, a gradual giving way of 
health, and the absence of any beneficial effect from remedies, point 



MENORRHAGIA. 113 

to an unfavourable termination, and lead to the conviction that there is 
beyond the reach of an examination, by the finger or speculum, some 
malignant structural change. 

Prognosis. — Dr. Churchill says, "Of all the cases I have seen, none 
have proved fatal, either directly or indirectly." This is more than I 
can affirm. Happily the malady is generally cured, or perhaps it 
would be more correct to say, that as the catamenial function ceases 
the bleedings cease also. If there be no latent tendency to malignant 
or pulmonary disease, it is not likely that such will occur. And it 
must be allowed, that women do sustain excessive and long-continued 
uterine hemorrhages, without a fatal result. But let it not be supposed 
that these formidable losses do not seriously injure the health. They 
deprive the body of that blood by which its solid structures are nou- 
rished, and thus lay the foundation of uterine softening. There is also 
a probability of dropsy, and the patient may be destroyed by phthisis. 

Treatment. — So much has been already said, that it is scarcely neces- 
sary to enlarge here. In the hemorrhagic intervals, if there be local 
or general plethora, a small bleeding, cupping on the loins, leeches to 
the anus or vulva; and if there be fulness, heat, and pain about the 
cervix uteri, scarification, as already recommended, may be practised. 
Sexual intercourse and stimulants, mental excitement and physical ef- 
fort, must be avoided for ten or twelve days before the periodical re- 
turns. When there is increasing pallor, oedema, threatened dropsies, 
softening of the cervix, and aggravated debility, — sea air, a mild but 
nutritious diet, consisting of animal food and milk, or malt liquor, must 
be enjoined. Where there is universal coldness of surface, especially 
of the extremities, frictions, by stimulating embrocations, the flesh-brush, 
and horse-hair gloves, the wearing of flannel and worsted stockings, 
are indicated. The salt hip-bath, the local salt shower-bath, applied 
night and morning, by a common garden watering pot, over the hypo- 
gastric and lumbar regions, are often advantageous. Nor is the injec- 
tion of cold water, once or twice a-day, into the rectum, to be forgot- 
ten. Astringent vaginal injections are deservedly relied on, espe- 
cially if carefully administered, as already urged (page 108), during the 
intervals. Still there are cases, and occasionally I meet with a good 
many, where cold injections cannot be borne. Local fulness, excite- 
ment and pain, follow their use, and sometimes I have attributed to 
their employment an earlier and larger return of the hemorrhage. 
They are most beneficial where there is copious leucorrhcea, and from 
the cure of this morbid secretion, good may be invariably antici- 
pated. It is to be remembered, that the unmarried are liable to conges- 
tive menorrhagia, and I have often thought, that their cure was more 
difficult and protracted, and their hemorrhages larger, than where 
many children had been borne ; but I am not prepared to give a posi- 
tive opinion. During an attack, the patient should lie on a hard mat- 
tress, be kept perfectly quiet, covered lightly with bed-clothes, and have 
warmth applied to the feet and legs; hot bottles, or mustard poultices 
may be used for this purpose. Her drink must be unstimulating and 
cold, except where there is syncope, and then wine in small quantities 
may be given. 



114 



MENORRHAGIA. 



I have for several years tried the ergot in these cases, and I think 
highly of its efficacy; but there are more than a few instances in which 
it has entirely failed, and several in which it has induced spasm and 
increased bleeding I have two patients who, for these reasons, always 
request that it may not be used. I prefer the tincture to the powder, 
and I give thirty drops for a dose. Frequently lead and opium, tur- 
pentine, muriated iron and opium (vide formulae), have proved service- 
able Cold to the lower abdomen and genitals, and particularly plug- 
o-incr the vagina with soft tow, where the loss is excessive, are effective 

remedies. 

Few cases will be introduced ; very few of every-day occurrence. 
But where the history and symptoms, the pathology or treatment ot 
menorrhagia require illustration, 1 shall not scruple, as briefly as possi- 
ble, to confirm the text by their insertion. 



Case 29. 

spasmodic menorrhagia. 

Jul,/ 24th, 1836. 1 visited Mrs. , *t. 37, a widow, residing at Walworth, 

and under my care as an out-patient of Guy's Hospital. She has never borne chil- 
dren, and is of spare habit, bnt neither weak nor emaciated. She has been menor- 
ibaaic for several years, and habitually suffers from dyspepsia, earning a l.vehnood 
by close application to her needle. Menstruation occurred two days since, and lor the 
last twenty-four hours, the paroxysms of pain and spasm about the uterus have been 
very severe. Much blood has been lost by gushes, and many large clots have been 
expelled. The spasm still continues, and on my visit I found the pulse quick {160) 
and irritable, but neither full nor hard. She is chill and faint; the countenance 
pallid and anxious : has had no sleep since the commencement of the attack, al- 
though there have been rather long intervals free from pain. At the commence- 
ment of the disease, three years since, she was bled and purged, but without any 
other than an injurious effect. Urine scanty and high-coloured. 

I ordered hot poppy fomentations to the abdomen, and the following mixture. 
R. Pulv. Ipecac, rad. 9i. Tinct. Camph. C. Jij. Mist. Camph. 5xiv. 
M. ft. Mistura. 
Take one teaspoonful every hour till nausea is produced. 
In the evening she was considerably relieved ; had taken six doses of the ipecacu- 
anha mixture, aTid was completely nauseated. The pain occurred at more distant 
intervals, and the flooding had nearly ceased. In a few days the menorrhagia passed 
off, and she recovered her accustomed health. For several subsequent periods she 
pursued ibis plan : and when 1 saw her six months afterwards, she informed me, that 
the menstruation was performed so naturally, that she had entirely laid aside the 
use of the medicine. 

There are numerous examples of spasmodic menorrhagia, espe- 
cially in crowded manufacturing towns. The treatment by bleeding 
and purging is too indiscriminately adopted; nor is it, at least very 
often, till the patient's health is decidedly injured, that a different plan 
is practised. I have repeatedly cured this form by nauseating and 
anodyne remedies. 



MENORRHAGIA. 1X5 

Case 30. 
congestive menorrhagia, nearly fatal. 

Ix 1833, I was asked by Mr. Rendle of Southwark, formerly a 
clinical clerk of Guy's Hospital, to see the following case : — 

Mrs'. ,aet. 42, of spare habit, the mother of several children, and compelled to 

work hard as a washerwoman, has long suffered from menorrhagia, — dating- its com- 
mencement from trie birth of her last child, now three years old. At times the 
bleedings have been less in quantity, but they have never entirely ceased. Till 
lately, the menstrual period has been nearly observed ; but recently, the losses have 
occurred at very short intervals, and she has been weakened and emaciated by their 
excess. Two days before my visit, menstruation commenced, with sensations of ful- 
ness and weight in the hypogastric region. For twenty-four hours there was no 
hemorrhage ; but soon afterwards, large eoagula passed, and an immense quantity 
of blood was lost. On our entrance, we feared she wasdying. The pallor and cold- 
ness of the face and extremities, the scarcely perceptible pulse and breathing, and 
the clammy perspiration of the surface, betokened the greatest danger. We stood 
over the bed, doubtful whether she would live or die. We feared to move her, 
lest fatal asphyxia should ensue; nor was it till we had waited several minutes, and 
she opened her eyes and breathed more distinctly, that we dared to give some ergot 
and brandy. At this moment, T wished to transfuse, and, had the apparatus been at 
hand, we should certainly have injected blood into her veins. As this could not be 
done, w T e repeated the ergot and brandy (vide formulae) several times, and the vagi- 
na was plugged. No further bleeding occurred, but the recovery was very slow. 

Case 31. 
protracted menorrhagia, terminating fatally, by phthisis and ascites. 

Mrs. T., aet. 45, an out-patient of Guy's, — is the mother of eight children, and of 
dark complexion. 

July 10, 1835. Has suffered from menorrhagia for three years, remedies having 
hitherto done little, if any good. The bleedings generally occur in connexion with 
menstruation, although floodings in the intervals have not been uncommon. Always 
and correctly prognosticates an attack, if she has, about the middle of the period, 
acute pain low down in the hypogastric region, with sensations of weight and ful- 
ness about the uterus. Pulse 110, and compressible; countenance pallid and sunk- 
en; bowels easily and frequently purged; urine scanty; perspiration frequent; 
marital intercourse, which rarely occurs, is often followed by bleeding. 

R. Secalis Cornuti 9ij. Morphias Acetat. gr. iss. Fern Sulph. gr. xi. 
Cons. Rosae qs. 
M. ft. pilulae xxiv. Take one pill three times daily. 
To use the tepid or cold hip-bath every evening. 

Two ounces of the compound alum injection three times daily, and to ab- 
stain from intercourse. 

July 30. Has had one excessive flooding since the last report ; stopped by cold, 
freely applied over the abdomen and loins, and cold alum wash injected into the va- 
gina. There is much leucorrhcsa, and frequent cough ; countenance pale ; more ema- 
ciated and increasingly weak. Cont. remedia. 

August 10. No better ; leucorrhoea still continues; pulse 120; feverish at night, 
with perspiration in the morning; complains of some, although slight pain, about the 
cervix uteri. To use an injection of sulphate of iron (vide formula?). 

R. Tinct. Ferri Muriat. Tinct. Secalis Cornuti. Tinct. Hyoscyami, aa 
3iv. M. ft. Mistura. 
Take thirty drops three times daily, in a teaspoonful of port wine. 



jig MENORRHAGIA. 

September 20. To-day she states that there is, and has been for the last few- 
weeks, a constant sanguineous discharge, not by gushes, but scarcely by more than 
a few drops at a time. Her legs pit on pressure, and they are cedematous and cold ; 
urine scanty and high-coloured; breathing short, and often difficult; leucorrhcea 
scarcely diminished ; cough short, hacking, and frequent, with a continuance of the 
momma perspirations. Her countenance has the sallow leaden hue, pointed out by 
Sir James Clark, in his invaluable practical Work on Consumption, as so character- 
istic of tuberculous cachexia, acquired in mature life. Is to go into Wiltshire, her 
native county, and to follow out the plan before pursued, and so fully pointed out in 

the preceding page. 

On examination I found the os patulous and large, the neck of the uterus sott, 
almost spongy, and entirely devoid of its firm, glandular feel. I carried my finger, 
without difficulty, into ihe'uterine cavity ; but 1 could detect no hard nor soft tu- 
mour. The uterus is not greatly increased in size, nor did any bleeding follow this 

inquiry. 

November 15 Her mother informed me that she had died about a month pre- 
viously, from dropsy and consumption, the bleedings continuing to the last. She 
was exceedingly emaciated. No examination was made after death. 

This case scarcely requires any comment. It is interesting, be- 
cause, happily, it is rare ; and the fatal pulmonary mischief is clearly 
attributable to the repeated bleedings. It cannot be said that there 
was no organic uterine change ; but it may, I think, be fairly assumed 
that the structural degeneration of the reproductive organs was not 
malignant. Such softening is, I believe, a frequent accompaniment of 
very protracted congestive menorrhagia, and points to the propriety 
of improving the health, and of restraining the hemorrhage, the for- 
mer condition being mainly dependent on the latter. 



Case 32. 

congestive menorrhagia and pregnancy. 

I had frequent occasion to see Mrs. ■—, set. 42, during the years 1837, 1838, 

1839, and several times in 1840. This lady was thirty-eight years old in 1836, had 
been married eighteen years, and was the mother of many children. Her health 
had been good during the whole of her married life, with the exception of slight ill- 
nesses connected with her various confinements. In 1837 she first suffered from 
menorrhagia, and in that, and the following year, the discharge was often so exces- 
sive as to°alarm her. Once I happened to be present, and certainly nearly two pints 
of blood were lost by gush in a few minutes. These attacks induced syncope and 
prostration at the time, and in the menstrual intervals there was pallor, weakness, 
and some emaciation. Tow, for the purpose of plugging the vagina, has often been 
in readiness; but her unconquerable aversion to this valuable remedy, has hitherto 
most improperly been allowed to prevent its use. The acute bearing pain, low 
down in the uterus, to which I have already alluded, invariably occurred about the 
middle of the interval, and was the certain precursor of a coming hemorrhage. IVor 
as a premonitory condition, were there ever absent, feelings of weight, t°r»sion, and 
distressing fulness in the lower part of the pelvis. Several times I satisfied myself 
by examination both by the rectum and vagina, that the uterus was really larger, 
and congested prior to menstruation. 

During the attacks, astringent vaginal injections, cold sponging over the loins, and 
pudendum, were freely employed. The ergot, in its various torms, the acetate of 
lead and acids, opium and turpentine, were all given. The recumbent position was 
long and strictly observed. 

In the intervals, tonics, stomachics, sea air and bathing, local salt water shower- 
baths, good diet, rest, and as much quiet as could be obtained, were insisted on. 

I am often very anxious about this case. There is emaciation, a sallow, wan 



MENORRHAGIA. 117 

countenance, impaired appetite, and great debility. Leucorrhcea is always present 
durincr the menorrhagic intervals, and it is sometimes slightly sanguineous and offen- 
sive ° I have repeatedly examined during the last two years. The os is constantly 
patulous, its lips swollen, and, together with the cervix, soft and flabby, bull, there 
has never been either hardness, fissure, or abrasion. 

After the continuance of the menorrhagia for more than three years and when ail 
idea of precmancy had been abandoned, conception occurred. Over-fatigue, the pa- 
tient being ignorant of her real state, produced abortion at the end of the third month 
(July, 1840). The ovum was quite healthy. 

This is one of a large class of cases. I need not say that they are 
perplexing and difficult. The protraction and the debility induced by 
the repeated hemorrhages, fully justify such a conclusion. But addi- 
tional confirmation of "the opinion is afforded by the possibility that 
structural malignant change or dropsies, or exhaustion, may destroy the 
patient. Congestive menorrhagia may, I think, more frequently than 
is supposed, be attributed to the avoidance of complete sexual inter- 
course, and to consequent derangement and congestion of the ovana 
and uterus. This abstinence is dangerously practised to avoid the risk 
of adding to the number of a family, already thought to be too numerous 
for the pecuniary means of its principal supporter. But this is ob- 
viously a subject on which one cannot, with propriety, enlarge. 



Case 33. 

CONGESTIVE MENORRHAGIA— DIAGNOSIS DIFFICULT. 

Mrs. , at. 52, has not been married, is tall, and of large make. Has always 

resided in or near London. Up to the time of her present illness, has enjoyed un- 
broken health, and has been remarkable for muscular strength and activity. In No- 
vember. 1836, when she was 48 years old, menstruation first became irregular, 
returnincr very profusely after longer intervals. Sometimes she was alarmed by the 
numerous and large coagula which passed, and by syncope; but she quickly rallied; 
and as she believed such occurrences, if not natural, were very common, she refused 
to adopt, anv medical plan, or to take any particular care. I frequently saw her 
during these" hemorrhages; she was chill, prostrate and faint; but. alter their subsi- 
dence, management was at end. 

In Auo-ust, 1838, almost two years after the commencement of the malady, there 
was emaciation, frequent hot flushes, and distress from heat in any form ; a blanched 
skin, a quick, vibrating pulse, and slight uterine pain. The patient could not walk 
so far, nor attend so energetically to her domestic duties. 

Prior to the occurrence of the menorrhagic attacks, Mrs. always com- 
plained of weight, fulness arid tension in the uterine region, of pressure*on the blad- 
der and dysuria, and occasionally of pain about the neck of the womb. In November, 
1838, I was allowed to examine both by the vagina and rectum. The body of the 
uterus was heavier and larger than natural ; the os somewhat patulous, and the cer- 
vix swollen. 1 did not use the speculum, as the hymen was firm, and presented even 
the easy passage of the finger; but I am confident there was no abrasion. All the 
parts were unusually soft "and flabby, but neither pain nor bleeding followed the 

inquiry. . , 

From 1838 to August, 1840, the course of this disease has been perplexing and 

unsatisfactory. 

In March and April, 1838, Sir James Clark was consulted— at that time her state 
was as follows: the general surface is pale and ensanguined; the least excitement 
quickens the pulse, and produces flushings of heat. The emaciation slowly increases ; 
there is oedema in various parts of the body, but no anasaica. Only slight uterine 



118 MENORRHAGIA. 

pain is complained of; but she has the appearance of a patient suffering from malig- 
nant disease. A continuation of the treatment was enjoined. 

The remedies have been the ergot in every form and dose ; turpentine; the acetate 
of lead; acids and refrigerants ; benzoin; opium; the various astringent, stimulant, 
and anodyne injections ; country and sea air ; spare and nutritious diet ; leeches and 
small bleedings; easy exercise in a carriage, and the recumbent position. But only 
transient benefit has been derived. Often in the last two years, I have given it up as 
ajost case, as there has never been a day during that time, without either sanguine- 
ous, sero-mucous or muco-purulent discharge; but alter I have arrived at this con- 
clusion for a week, perhaps for several, the discharges decline, there is no uterine 
pain, there is a rally of the strength ; she becomes cheerful, walks about the garden, 
sleeps better, enjoys her fond, and gathers flesh ; thus leading one to doubt, whether 
this may not be a very rare example of protracted, congestive menorrhagia, without 
any more than the usual non-malignant chancres of structure. 

feeveral circumstances deserve attention in this case. The patient is often entirely 
free from sanguineous loss for three or four weeks; but its place is always sup- 
plied by copious discharges of sero-mucous, not aqueous, and occasionally of muco- 
purulent or purulent fluid ; generally as many as eight, nine, and ten napkins are 
used daily, and when the sanguineous discharge is present, many more are required, 
so that it is impossible not to wonder how these large and constant drains are 
borne. 

The hemorrhages are invariably preceded by sensations of uterine congestion, and 
several times a clot has been passed entire, presenting an accurate cast of the uterine 
cavity. From its comparatively small size, and unaltered form, an inference has 
been drawn that this viscus is still of nearly normal volume. 

There is scarcely any pain ; none of a severe or permanent kind : an anodyne has 
never been required for its alleviation. An examination made a few days since 
(August. 1840), both by the rectum and vagina, reveals no traces of disorganization. 
The os is patulous, and its edges are large and swollen ; the cervix too is more bulky, 
but beyond these changes I can discover nothing abnormal. 

I have dwelt at some length on this case, because I know it is but 
of rare occurrence. A positive opinion cannot be given. My own 
leans to its malignant character. The emaciation, the repeated bleed- 
ings, the constancy of the serous, the muco-serous, and purulent dis- 
charges, the gradual diminution of strength, and the trivial benefit 
derived from remedies, all point to disease of this kind. Still no care, 
no remedy at all likely to exert beneficial control, should be withheld. 
The patient ought to be encouraged, and especially on the ground, that 
her long struggle may terminate in a stationary, inactive condition of 
the disease, and perhaps in recovery. 

I could add several examples of protracted congestive menorrhagia, 
where the congestion was consequent on a loaded condition of the bowels 
and luxurious living. To these, as causes, allusion has been already 
made. In one instance, where the patient was middle-aged, and the 
landlady of an inn, nearly constant hepatic and intestinal derangement, 
as well as increased bulk of the liver, were thus induced. The menor- 
rhagic attacks were most frightful, and on not a few occasions, there 
was great difficulty in rousing her from the consequent syncope. The 
late Dr. Cholmeley visited her, and stated that she might be cured by 
spare diet and purgatives. The importance of these measures was 
enforced, and in a few months the hemorrhages were prevented. I 
mention this ease especially, to show the value of purgatives prior to 
the anticipated return of the menstrual period. I often ordered for this 
patient, after the disease had continued some time, a full dose of castor 



MENORRHAGIA. 119 

oil, twenty-four hours before the expected commencement of the dis- 
charge, and with the best results. Dr. Locock observes, u that m ex- 
araufes of this kind of menorrhagia, the next return of menstruation 
may be rendered comparatively trifling, by the use of a fall purgation 
about twenty-four hours before the period, when that can be ascer- 
tained, avoiding every medicine of a drastic, stimulating nature.' He 
also adds, thus confirming what I have just advanced, " that chronic 
(congestive) menorrhagia is occasionally connected with organic or 
functional disease of the hepatic system ; and when it is recollected how 
notoriously inattentive women are to the state of their bowels, and what 
enormous accumulations of fcecal matter are allowed to take place, it 
may easily be supposed to what degree the abdominal circulation must 
become obstructed, and how powerfully such obstruction must act in 
producing congestion of the plethoric viscera.'' 

In conclusion,! think it right to observe, that I have twice witnessed, 
in most extreme cases, the beneficial effects of injecting into the uterine 
cavity a small quantity of the spirit of turpentine. It will not be sup- 
posed, after what I have heretofore said, that I advise this procedure on 
slight grounds. I believe such injections to be very certain but highly 
hazardous remedies, and they never ought to be employed except as 
derniers resorts. The uterus also has been injected with a small quan- 
tity of lead and alum in solution; and the narrator of the treatment 
savs, " the remedy is a dangerous one, for in two instances it was fol- 
lowed by vomiting, uterine inflammation, and death." At page 243, 
vol. II. of Guy's Hospital Reports, and at page 64 of the present work, 
additional cases and observations will be found. 

I first employed the turpentine in a menorrhagia where every pre- 
vious remedy had proved ineffectual. The case is as follows :— Mrs. 
G,, forty-five years of age, and habitually intemperate, requested me 
to give her some medicine to prevent hemorrhage from the womb. 
She was large, and rather bloated, but still capable of great exertion. 
She was married, was the mother of several living children, and had 
miscarried a few months previously. I remonstrated with her on the 
excesses to which she acknowledged she was prone, and fully ex- 
plained to her, that they were the source of the bleedings. The uterus 
was large and soft, and the cervix was full and flabby : but although 
the os was sufficiently patulous to permit the entrance of the finger, I 
could not detect further structural change. An examination by the 
rectum was also made. She lived in my immediate neighbourhood, 
and as I had frequent opportunities of seeing her, she adopted for a 
time, the prescribed plan and diet. By purging during the intervals, 
and especially before the period, the losses were for a few months 
greatly diminished. At length she thought herself so well, as to be 
no longer under the necessity to adopt any plan which curtailed her 
usual indulgences. I lost sight of her for some months, and I know, 
during the interval, that highly-seasoned food and large quantities of 
ale and wine were taken daily. One evening, I was requested in haste 
to visit her, and 1 found her almost dead from uterine bleeding. Her 
husband informed me, that since my last attendance, she had very 
frequently lost large quantities of blood, and he had thought that on 



120 MENORRHAGIA. 

several occasions she must have died, but that hitherto she had always 
slowly rallied. Brandy and ammonia and ergot restored animation, 
but she had not said many words before a fresh gush again induced 
alarming syncope. Cold water was dashed over the face, ammonia 
was applied to her nostrils by a camel-hair pencil, and after a very 
lengthened fainting, she again rallied. On inquiry, I found the attack 
had already lasted two days ; and it was evident that her powers were 
exhausted. Her voice was scarcely to be heard,' the pulse was quick 
and feeble, and her breathing was very short, the countenance was 
livid and anxious; in fact it seemed as though another gush would 
destroy her. Her medical attendant, Mr. Burton, plugged with 
sponge, but ineffectually. On the instant I proposed to inject a small 
quantity of spirit of turpentine ; and having procured a gum-elastic 
male catheter, and cut off its end, so that there was an open mouth, I 
introduced it through the os, which was very patulous, into the ute- 
rine cavity, and by a syringe I injected about two or three drachms 
of the spirit. Soon afterwards I plugged the vagina with tow. There 
was no further bleeding, but the pain was indescribably great, as 
though there were burning coals in the uterus and bladder. The evi- 
dences of hysteritis seemed so clear, that I feared we must have taken 
away blood. Fomentations of poppy and conium applied very hot; 
camphor and laudanum, together with a purgative enema, allayed the 
intense suffering. In twenty-four hours I removed the tow, and there 
was no further bleeding. Menstruation never returned, and from the 
continued and occasionally severe pain which followed the use of the 
turpentine, I suspect that adhesion of the sides of the uterine cavity 
resulted from the inflammation. Her former intemperate habits were 
soon resumed, and in less than a year she died. No inspection could 
be obtained. 

I again witnessed the advantageous effect of this remedy in July, 
1838.; On that occasion I was requested to visit a lady under the care 
of Mr. Price of Margate. On my arrival, the following particulars 

were communicated to me : — Mrs. M , set. 45, is the mother of 

several children, and has suffered from menorrhagia for two or three 
years : of late, the losses had been large, and she had repaired to the 
sea-side for a restoration of health. Two days before my visit, July 
17th, the period returned, and in a few hours much blood was pumped 
out of the uterus by gushes. Mr. Price promptly, but without stopping 
the hemorrhage, gave large doses of ergot, acetate of lead, and sulphu- 
ric acid, at the same time applying cold externally, and injecting as- 
tringents into the vagina. It soon became evident that more must be 
done, and Mr. P. boldly determined to throw a small quantity of tur- 
pentine into the uterine cavity. On my arrival this had been effected 
some hours ; the bleeding had ceased, and she appeared to have all 
the symptoms of hysteritis. The agonising pain, described in the pre- 
ceding case, 'was present, requiring aid to keep her in bed. The pulse 
was 140, irritable and thrilling, but compressible, and without hardness 
or power. The abdomen was painful to the touch, but not in the same 
way as in puerperal fever. The pain had aggravations and intervals 
of less severity, and it was not necessary, as it often is in puerperal pe- 



MENORRHAGIA. 121 

ritonitis, to prevent the pressure of the bed-clothes by placing a cradle 
over the patient. Still the sufferings were described as almost unen- 
durable. Opium, a purgative enema, and afterwards a suppository, 
together with anodyne and mustard fomentations, palliated the pain ; 
and, under the influence of a full opiate, she got some refreshing sleep. 
The vagina had been plugged prior to the injection of the turpentine, 
and before we left her for the night, I carefully filled it with tow, 
wetting it afterwards by a syringe with decoction of ergot (vide for- 
mulae). In the morning there had been no return of hemorrhage, and 
I was subsequently informed, by Mr. Price, that she had recovered 
well, but slowly. 

In cases of alarming menorrhagia, it is a matter of moment that the 
practitioner remain with the patient and ascertain very frequently the 
extent of the hemorrhage. In puerperal bleedings, after the expulsion 
of the placenta, life is often dependent on this precaution. A crown 
princess of Austria, who had been attended by the celebrated Boer, 
of Vienna (the ease is related by Dr. Rigby), and many other women, 
have been lost from the neglect of its observance, and in the instances 
now under inquiry it is scarcely less necessary. After excessive me- 
norrhagic bleeding by gushes, or in a stream, the powers of life are 
often reduced to a very low ebb ; and protracted but slight drainings 
may therefore afterwards insidiously and unexpectedly sink the pa- 
tient. 



CHAPTER VII. 

OF LEUCORRHOSA. 

Definition. — fin excessive and altered secretion of the mucus, furnished 
by the membranes luring the vagina and uterus, by the follicles of theinte- 
rior of the cervix uteri, and by the lacunae of the vestibulum, generally 
white or nearly colourless and transparent, usually without much odour, 
glutinous, muco-purulent, or purulent, sometimes yellow-green, or slightly 
sanguineous, and of varying degrees of consistence. The amount of 
constitutional derangement depending on the severity of the affection and 
the susceptibility of the patient. 

There are three forms of the disease. 

First, The common leucorrhoea, often mild, sometimes acute. 

Second, The inveterate and chronic leucorrhoea. 

Third, The symptomatic leucorrhoea. 

Acute and mild leucorrhoea. 

History and Symptoms. — I have adopted this division, because it is 
both correct and comprehensive. It is proper to distinguish a recent, 
common, and inflammatory leucorrhoea, from one of the same order, 
only of chronic inveteracy. And it is certainly not less correct to dis- 
tinguish both these from "the symptomatic form, when the discharge 
owes its origin and continuance to structural or malignant changes of 
the uterus or its appendages. It is also comprehensive, not only in- 
cluding the examples where the pathological condition is inflammation 
or simple uterine catarrh, but also the symptomatic cases, where 
changes of a more serious or disorganising kind are the source of the 
mischief. Of all the diseases peculiar to the sex, there is none so 
common. Few married women, particularly if they are mothers, 
escape its attacks. The young and the robust are less liable than those 
more advanced in life, especially if the latter possess susceptible and 
delicate constitutions. If evidence were required of its almost uni- 
versal prevalence, it might be found in the number of its synonymous 
names, in the vast variety of real or supposed remedies, and in the 
many treatises published to elucidate its nature. In its milder forms, 
there is so little pain and constitutional disturbance, so little interference 
with the uterine functions and the comfort of the patient, that we can- 
not wonder at its neglect. And yet I believe, if care were taken at 
this early stage, if ablution only was frequently practised, the tone of all 
the parts, and more particularly of the secretory membrane, would be 
regained, and further mischief entirely prevented : so far as my obser- 
vation has gone, there is amongst female youth, and women generally, 
in this country, an unfounded dread of ablution of the external organs, 



LEUCORRHCEA. 123 

either cold or tepid. The vicissitudes of our climate in some measure 
account for and justify the impression, but nevertheless it is too general, 
and extensively injurious. The duration of the affection has often as- 
tonished me; many individuals stating that they have suffered from it 
for years, and some few during the whole of their lives. But it is dis- 
ease still ; for in health there is an accurate relation between the 
amount of secretion and the purpose which it serves, viz., lubrication 
of surface. When, from any cause, its amount is increased beyond 
what is necessary for this important end, it is morbid ; although, in 
many instances, remedies are scarcely required for its cure. It was 
stated, when treating of menorrhagia, that climate and peculiarity of 
constitution were criteria of importance in determining whether men- 
struation was morbidly profuse. The observation is partially true of 
leucorrhoea, as in hot climates and in marshy districts — in Holland 
for example — there is a larger quantity of mucus naturally secreted 
than in drier and more temperate regions. I do not wish to extend 
these general observations; but still, without some clearing of the 
ground, it will be very difficult to convey any correct ideas of the dif- 
ferent degrees, and of the various seats of this prevalent malady. 
Thus, although the vagina is the common outlet for all leucorrhceal 
discharges, it must not be forgotten, that these differ much from each 
other, being furnished by parts of different structure and vascularity, 
whose healthy secretions are far from identical. A precise knowledge 
of these differences will not only assist us in the diagnosis, but will 
also render our treatment more efficient. 

The mucus naturally secreted by these various parts, although not 
entirely the same, does not differ in any of its essential properties from 
mucus furnished by similar membranes in other parts of the body. 
It consists of albumen and soda, and in transparency, colour, and 
viscidity, it closely resembles the white of an egg in its natural state. 

The mucus secreted by the lining membranes of the uterus and Fallopian 
tubes ^ is correctly characterized by the above description. Its purpose 
is, such a degree of lubrication of the sides of the tubes, and of the 
opposing surfaces of the uterine cavity, as shall prevent their adhesion. 
It need scarcely be added, that a very small quantity is sufficient, and 
that with the exception of the period of pregnancy, when the decidua 
covers the membrane, its secretion must be constant. 

The mucus furnished by the lining membrane of the vagina, is more 
abundant in quantity and less viscid, than the uterine mucus. This 
fact is readily proved by examination under procidentia. If the finger 
be merely introduced into the vagina and withdrawn, it will be covered 
by a thin mucus only ; but if it be carried, as it often may, through the 
os into the interior of the uterus, the adherent mucus will be found 
much more ropy and tenacious ; generally, indeed, it may be consider- 
ably drawn out without breaking. 

The mucus furnished by the lacunce of the vestibulum, or that part of 
the vagina external to the hymen, is probably slightly more tenacious 
than the vaginal secretion, and is said to exhale a peculiar odour, 
Whether it possesses this latter property independently of pregnancy or 



124 



LEUCORRK(EA. 



morbid action, or in higher degree than the mucus furnished by other 
parts, admits, I think, of doubt. ■ . 

The secretion from the glands of the interior of the cervix uteri, is 
not often found in common leucorrhcea. I had lately an opportunity 
of examining these glands and their product, in a patient who had died 
in early pregnancy. The glands themselves were numerous and clearly 
discernible, and the mucus was easily drawn out entire and unbroken. 
Sir Charles Clarke, whose work on Female Diseases cannot be too 
highly esteemed, says, " that this mucus contains a smaller proportion 
of water than any other, approaching nearer to the nature of a solid 
than a fluid body. These glands, in a state of health, perform the 
office of secretion in pregnancy only ; or, if at any other time, the 
matter secreted is of a very different kind, so resembling common 
mucus as not to be distinguished from it." 

A remembrance of these facts will aid us in forming a correct opi- 
nion of the nature and precise seat of the several forms of the disease. 
If then, these secretions differ from each other in health, doubtless 
under various degrees of irritaticn and inflammatory action, a similar 
difference will be apparent. The simplest idea of leucorrhcea is ob- 
tained, by regarding its mildest acute form as the result of mere hy- 
peremia or vascular congestion, whether it affect one only, or all 
the parts enumerated in its definition. Under such an amount of mor- 
bid influence, the secretion furnished by these various parts will be 
more abundant than in health ; but it will retain its natural characters 
it will still be a white, transparent, and glutinous mucus ; there will 
be derangement of system, produced by febrile excitement, slight ardor 
urinae, and some sensations of heat and tenderness about the generative 
organs. It is easy, after this description, to understand the transition 
to its more serious forms, where the healthy properties of the mucus 
are lost ; where it has become not only excessive in quantity, but muco- 
purulent, entirely purulent, or ichorous and watery, and of yellow, 
green or sanguineous colour; and where the constitutional affection 
is acute and extensive. Here we shall have no hesitation in believing, 
that congestion and irritability have been succeeded by inflammation, 
and that whether several only, or all the parts are affected, they have lost 
their healthy secretory action, and are pouring out pus, the proper and 
usual product of an inflamed mucous membrane. Nor is this statement 
less true of the third or symptomatic form, where the discharge is the 
consequence of any of the grave structural lesions, of which it is so 
constant an accompaniment. . 

Often, in common leucorrhcea, I have examined by the vagina, but 
without discovering more than a trifling increase of the body of the ute- 
rus, some tenderness of the cervix in the inflammatory form, but none in 
the protracted or chronic variety. The state of the cervix is occa- 
sionally soft, and the os rather patulous. Sometimes the orifice is not 
at all open, but generally the whole of these parts are supple, bathed 
in discharge, and much more relaxed than in health. In several in- 
stances where I have used the speculum, the cervix has been pale, in 
more acute cases slightly red, and in two severe attacks, it was of a 
deep crimson tinge. In none where there was not suspicion of vene- 



LEUCORRH(EA. 125 

real taint, have I seen erosion or ulceration. A few days since I had 
an opportunity of examination, and there were three distinct and large 
patches of superficial ulceration on the cervix; but the other symptoms 
were too unequivocal to leave any doubt of the presence of gonorrhoea. 
I have already stated, that the discharge varies much in quantity ; some- 
times it is so profuse as to oblige the patient to change the napkin seve- 
ral times daily; at other times it is less in quantity, but acrimonious; 
and in colour and consistence there is almost endless variety. 

Viewing the different forms in this way, there will be less difficulty 
in assigning to each either a mild, aggravated, or symptomatic cha- 
racter. Examples of the least severe kind, arising from excitement, 
are most frequent. The blood-vessels of one or several of the secre- 
ting parts, from increased circulation, become congested, and soon 
afterwards excessive secretion, constituting the leucorrhcea, takes 
place. In many of these instances, the augmented secretion is proba- 
bly confined (and in this idea Dr. Burne concurs) to the muciparous 
glands of the ostium or entrance of the vagina, scarcely affecting the 
membrane of the whole canal, much less the uterine secretory surfaces. 
This opinion becomes highly probable from the fact, that recent and 
mild leucorrhcea often yields to ablutions and lotions, applied, not as 
injections, but as washes to the external parts, the genital fissure being 
exposed by the separation of the labia. Here the accompanying symp- 
toms will be so slight, as scarcely to secure the attention of the pa- 
tient. From this incipient and mild form, every degree and variety 
will be met with, up to the most aggravated and symptomatic exam- 
ples of the affection. In some, the vascular excitement and irritation 
will be more marked, and the local symptoms and constitutional de- 
rangement more distressing. The discharge may not only be exces- 
sive, but highly irritating, and there may be ardor urinae, heat of the 
genital fissure, and dysuria. But this assemblage of symptoms, con- 
stituting a case of acute, inflammatory leucorrhcea, may quickly yield 
to ablutions of tepid water or poppy fomentation, aperients, abstinence 
from intercourse, spare diet, and rest. These, therefore, are not the 
cases in which medical aid is anxiously sought. But in a still more 
severe attack, where, from any of the causes to be hereafter specified, 
inflammatory action has been followed by excessive and acrimonious 
secretions, the symptoms will generally prompt the patient to seek im- 
mediate relief. In such, there will be rigors, from sympathy with the 
uterus, heat of surface, a quick pulse, and white tongue, pain in the 
loins and hypogastric region, heat and pain about the cervix uteri and 
neck of the bladder, affecting also the vagina, urethra, and external 
parts, distressing ardor urinae, and strangury. These symptoms may 
continue one or several weeks, according to the treatment and its 
success. If, under the idea of its being a "weakness," tonics and 
stimulant injections are early exhibited, the discharge will probably 
become more excessive, purulent or mucopurulent, thin and watery, 
or ichorous, and the constitutional effects more aggravated. If, on 
the contrary, antiphlogistic and soothing treatment be adopted, the 
morbid secretion will diminish in quantity, and the general derange- 
ment will disappear. In many instances, the cure is quickly effected ; 
9 



j26 LEUCORRHCEA. 

but in some, even where proper treatment is early and fully pursued, 
it lasts long, proves very troublesome, and eventually passes into a 
chronic and inveterate state. It need scarcely be said that the dis- 
charges in the varieties now pointed out, originate in increased action 
of the vessels of the different parts. Females, therefore, of plethoric 
habit, possessing more than ordinary vigour of constitution, are more 
liable to such attacks than those who are feeble or less strong. And 
as the former is not so numerous a class as the latter, it may be af- 
firmed that leucorrhcea, attended by weakness, is the more common 
form. Yet it must be remembered that some females indulge in the 
pleasures of the table, and drink too freely of malt liquor, wine, or 
spirits. In many affections thus produced, the cares of a family or a 
business, or more frequently the disinclination to exercise, or eventually 
the want of strength sufficient to bear its inconveniences, almost com- 
pel a sedentary life. Hence they become corpulent, but not strong; 
a larger quantity of blood is generated, vessels scarcely to be seen 
before become visible, the pulse is full, the respiration is embarrassed 
on slight exertion, and the functions of the bowels and the kidneys are 
badly performed . In these examples, and they are not very uncommon, 
particularly about the middle period of life, menstruation often be- 
comes profuse, and the leucorrhcea excessive. Great care is required 
in the treatment; for if these undue secretions are suddenly stopped, 
apoplexy, inflammation of the liver, of the stomach or bowels may su- 
pervene and the patient be quickly destroyed: in the section on treat- 
ment these circumstances will receive their full share of attention. In 
the various degrees now pointed out, leucorrhcea is a common sexual 
malady ; nor is it difficult to believe, from the complication of its causes, 
the susceptibility of women, the frequent neglect of all treatment and 
the injudicious management so often adopted, that every variety of 

case shall arise. 

Second, Chronic and aggravated leucorrhcea. 

It is in this form, not in the preceding, that the cure is difficult. 
The history of these more serious cases is instructive; because it gene- 
rally reveals early neglect or improper treatment. Some females, 
however, seem to be almost naturally the subjects of discharges, unu- 
sual in amount as well as in character. In many instances, amongst 
the out-patients of Guy's, these leucorrhceal discharges are so habitual, 
that complaints of congestion in other parts, about the head or chest, 
pains in the limbs, or neuralgic pains of the abdomen, are almost inva- 
riably complained of for some weeks after the excessive and morbid 
secretion has been entirely or even partially cured. Nor is it at all 
uncommon, when many remedies have been tried, without benefit, 
that the disease is allowed to take its course uncontrolled. The fre- 
quent results are, sterility, from ansemia of the reproductive organs, 
especially of the ovaria, prolapse and procidentia of the uterus, and 
not unfrequently of the vagina and bladder. 

It need scarcely be added that pallor, partial emaciation, or rather 
thinness of person, indigestion, impaired appetite, and constipation, 
languor, and weakness, are the constitutional accompaniments. In 
some instances (vide cases), the continuance and aggravation of the 



LEUCORRHCEA. . J27 

leucorrhoea is the fault of the practitioner. Uterine or general plethora 
has been overlooked ; the morbid state of the cervix or body of the 
uterus has been disregarded ; abrasion or ulceration affecting these 
parts of the vagina may not have been discovered, because an exami- 
nation by the speculum, or the finger, has not been made. Thus what 
was at first, and for some time, a case of aggravated and chronic 
leucorrhoea only, becomes, in the progress of the morbid action, an ex- 
ample of the symptomatic form, and requires for its cure a much more 
local application of stimulant and alterative remedies. I have known 
two examples where severe and primary attacks of leucorrhoea, were 
rendered chronic and aggravated by an unnatural heat of the external 
parts, produced and maintained by the constant wearing of thick nap- 
kins, to secure the patients against the discomforts of large discharges, 
which were, by this measure alone, rendered still more excessive and 
constant (vide cases), a greater supply of blood being thus induced. 
Where the leucorrhoea is chronic and aggravated, there is great vari- 
ety in the discharge. Sometimes it is glutinous, transparent, and 
colourless— the natural secretion in excess — at other times it is deci- 
dedly purulent, muco-purulent, or watery, the result of inflammation 
changing the action of the parts. Nor is the colour less variable : a 
green or brown tinge may indicate excessive irritation, and blood 
mingled with the discharge will probably result from abrasion or 
rupture of the capillaries of the uterine surface, or it may announce 
the approach of the catamenial period. 

After these observations, it will be understood that the general health 
may be fearfully and sometimes, although very rarely, fatally broken 
down by chronic and inordinate leucorrhoea. If it exist in the young, 
or in those who have scarcely passed twenty years of age, amenorrhcea 
and chlorosis, with their numerous evils, and ultimately phthisis, may 
occur. Nor would these results appear so astonishing, if by accurate 
inquiry the quantity of mucus, constantly secreted, was really known. 
It would then scarcely surprise us that a girl, delicate perhaps from 
birth, or who, at least, may never have enjoyed good health, should 
eventually die from consumption, to which she may have had a latent 
tendency, after a drain of blood for months and years, sufficient to 
furnish an ounce, or several ounces, of leucorrhoeal secretion daily. 
Nor is it more to be wondered at in married women, that menstruation 
should be long suspended, and that conception should be prevented 
during the exhaustion produced by these discharges. It cannot, I think, 
with truth be affirmed, that changes of structure never occur in con- 
nexion with protracted leucorrhoea, although it may probably be 
satisfactorily proved, that malignant lesions are not within the scope 
of its morbid power. Softening of parts and partial disorganization 
of the uterus may, according to Andral and my own observation, 
take place. I know that a brain may soften, and purulent deposit be 
found in its substance, as the effect of undue lactation, and there is 
clearly no reason why some similar effect should not happen to the 
uterus from excessive and protracted leucorrhoea. 

Patients often think because the pain and heat and constitutional 
disturbance continue or are frequently repeated, that formidable uterine 



128 LEUCORRHCEA. 

disease must exist. This opinion is strengthened by the acrimony and 
odour, and the occasional sanguineous tinge of the discharge. Doubt- 
less, under such circumstances, examinations by the speculum and 
finger ought to be made ; but, even in their omission, a hasty conclusion 
should not be formed, as these symptoms often occur in afunctional but 
severe and protracted case. 

There must be noticed also a form of the malady, by some authors 
denominated the passive, but for which a better appellation, judging 
from its permanency, would be habitual leucorrhcea. In many in- 
stances it is the consequence of acute and inflammatory attacks ; but 
in still more of constitutional and local weakness. The generative or- 
gans of most leucophlegmatic females are habitually relaxed, and there 
are not a few where a very small quantity of mucus seems naturally 
to exude from the surface of the genital fissure. To this condition I 
have already alluded as one not generally deserving to be regarded as 
morbid, and only requiring for its control careful and repeated ablu- 
tions. But this habitual and trivial discharge, dependent originally on 
constitution, climate, and temperament, may become morbid by its 
excess ; especially when it coexists with amenorrhcea and chlorosis. 
Nor must it be forgotten that it has been cured, when of long standing, 
by marriage, and by the re-occurrence of menstruation. 

It is rare in the young, and common in married women, to whom 
there belong the general conditions already described, and whose 
strength has been weakened by sexual excess, monorrhagia, abortion, 
or over-lactation ; these having perhaps induced displacement and pro- 
lapse of the uterus. The symptoms are slight, and there is scarcely 
any local irritation. The discharge is generally white, stiffening the 
linen ; and if there be a neglect of cleanliness, it may produce inflam- 
matory abrasion of the upper part of the thighs and heat of the labia. 
The constitutional effects are trifling ; and yet such a patient will often 
by pallor of face and darkness round the eyelids, languor and inca- 
pability of exertion, afford sufficient indications of the existence of a 
weakening malady. Occasionally, where the disease has been long 
unchecked, and where the discharge is on the increase, there will be 
emaciation, constipated bowels, and depraved appetite and indigestion ; 
and I have often known such patients complain of pain in the stomach 
when empty, of a desire for food, without being able to take any, at 
least with relish, and of dragging and heavy feelings in the abdominal 
and lumbar regions. The complexion is often sallow and icterode, 
and several times I have had great difficulty in curing eruptions about 
the face and forehead, which have long existed in connexion with this 
form of leucorrhcea. 

Third, The symptomatic leucorrhcea. 

To a certain extent all that has been heretofore advanced is appli- 
cable to the symptomatic form. Most of the symptoms already point- 
ed out will exist here ; but with great variety as to their causes and 
relief. For example, a transparent mucous discharge is equally an 
attendant of prolapsus uteri, as of inflammatory uterine catarrh : but 
the accompanying symptoms are widely different ; nor can the cure 
be accomplished by the same means. Again a muco-purulent, or pu- 



LEUCORRHCEA. 129 

rulent secretion, may result not only from acute inflammation of the 
uterine mucous lining, but from a cancerous or sub-mucous tumour. 
The cure in the one case may be effected with comparative ease : in 
the other relief only, and that not without difficulty and delay, can be 
expected. The symptomatic form of the disease is therefore deserving 
of especial notice ; but, as in subsequent parts of the work it must be 
the subject of remark, in connexion with the structural lesions of which 
it is so frequent an accompaniment, it is not necessary at present to 
make more than these few observations. 

The importance of accurate examination by the finger and speculum, 
where the leucorrhcea is suspected to arise from lesions of an organic 
kind, can scarcely be too strongly urged. Nor ought it to be forgotten, 
that more than one such inquiry may be required, as an affection at first 
confined within the limits of functional disease, may, in its progress, 
acquire a totally different character. 

There is a peculiar form of leucorrhcea somewhat allied to hydrome- 
tra, inasmuch as the contents of the uterus in this latter disease are not 
always serous, but sometimes albuminous and muco-purulent secre- 
tions. In this variety the discharge does not consist of a limpid glairy 
fluid like common mucus, nor does it come away gradually as in com- 
mon leucorrhoea ; but the fluid is often entirely purulent, or so closely 
resembles pus, as to be with difficulty, if at all, distinguished from it, 
either in colour, viscidity, or odour ; and having accumulated in the 
uterine cavity, to four, five, six, or more ounces, it comes away by a 
gush. In these particulars it differs widely from ordinary leucorrhcea, 
and in one example, I thought, from the suddenness of its escape, and 
the similarity of the previous symptoms, that the discharge must have 
been the result of abscess. This opinion, however, was not confirmed 
by subsequent events. In all the instances falling under my observa- 
tion, and they are comparatively rare, rauco-purulent leucorrhoea had 
long existed previously, and although it was suspended during an 
accumulation going on in the uterine cavity, it returned immediately 
after the escape of the purulent gush. It is true, nevertheless, that the 
symptoms assume a character distinct from any other form of the malady, 
as the time for the eruption approaches (vide cases). There is fulness 
about the hypogastrium, a sense of constriction and weight about the 
neck of the bladder and along the course of the rectum, dysuria, heat, 
general uneasiness, and sometimes acute pain with forcing about the 
uterus. In one instance, the patient was so distressed by these, that she 
was compelled to keep her bed for several days prior to the escape of 
the pus. The general health suffers from the repetition of this series of 
morbid actions. 

Sometimes there is emaciation, and there is usually great difficulty in 
the cure. In two instances where widows were its subjects, the dis- 
ease disappeared after marriage, pregnancy having soon occurred. I 
have several times examined prior to the escape of the fluid ; the ute- 
rus has been generally but not greatly enlarged ; the cervix swollen 
and slightly tender, and the os partially closed. In no case has an 
examination revealed subsequent structural mischief, and in none that 
I have seen has the uterus been sufficiently voluminous to render it at 



130 LEUCORRHOEA. 

all probable that it should be mistaken for an ordinary case of hydro- 
metra. I have never seen this affection in young females. Married 
women, and particularly widows, or those in whom the reproductive 
organs having been employed are so, no longer, seem to be its most 
frequent subjects. 

I have thus attempted to elucidate the history and symptoms of this 
prevalent disease, without adopting the division into vaginal and ute- 
rine leucorrhoea. Independently of symptoms, it is allowed to be very 
difficult to distinguish what portion of two continuous membranes of 
identical structure are morbidly furnishing a nearly identical secretion; 
it seems much easier and more rational that the diagnosis should rest 
on the severity of the symptoms and the difficulty of cure* It is known 
that the vagina is much more frequently the seat of disease than the 
cavity of the uterus, and, in the majority of instances, it yields more 
readily to remedies. Thus, where there is marked aggravation of 
symptoms and considerable constitutional derangement, the uterine 
membrane is probably implicated ; but where, on the contrary, the 
whole of the symptoms are locally and constitutionally slight and 
easily cured, the vagina will generally be found to be the seat of the 
disease. The frequent implication of both the vaginal and uterine 
secretory surfaces, and the difficulty even where one only is morbidly 
affected, of distinguishing which it is, will often perplex the diagnosis, 
whatever divisional arrangement may be adopted. 

Causes. — These are numerous, and, according to their nature, have 
a distinct influence in the production of the different varieties of the 
disease. 

The first form, which I have denominated the common leucorrhoea, 
and which is more idiopathic than the others, owes its origin, especially 
in delicate and strumous females, to causes inducing increased action, 
and sometimes inflammation in the secretory surfaces and glandular 
apparatus of the genital organs. These are, the application of cold or 
moisture, frequent excitement resulting in debility from excessive sex- 
ual intercourse, abortions, from which the patient has only imperfectly 
recovered, quickly-recurring labours, puerperal hemorrhages, menor- 
rhagia, profuse menstruation, and undue lactation. The irritation of 
a pessary, or of stimulant injections on the vaginal surface and the 
cervix uteri, belong also to this class. There are other causes which 
act only indirectly, and these, with the agencies- already pointed out, 
may lead, where the common, mild, and more idiopathic disease is 
uncured, to the chronic and aggravated form. These operate through 
the medium of the nervous system and by sympathy. Thus in amenor- 
rhoea, where the functional or organic nerves of the uterus are affected, 
a leucorrhoeal secretion is frequently set up, not only from the vaginal, 
but likewise from the uterine mucous surface. Intemperance in eating 
and drinking often induces derangement of the stomach, bowels, and 
liver ; by sympathy with these, morbid actions of the uterine system 
may be induced, and leucorrhoea will often be the result. Nor must 
irritation of the spinal marrow be omitted in this enumeration. I lately 
saw an example where leucorrhoea might be traced to morbid affec- 
tion of the cord in the sacral region, as evidenced by tenderness 



LEUCORRHCEA. 131 

when these parts were pressed. Here there was an unusual degree of 
lumbar and sacral pain, much more than could be fairly attributed to 
the quantity or continuance of discharge. In such, a cure is obtained 
by rest, leeches, and stimulating embrocations about the loins and 
sacrum. Still, I do not wish it to be understood that dorsal, lumbar, 
and inguinal pains, are the concomitants of leucorrhcea of this alone. 
For I am quite aware that these symptoms are attendants on cases of 
leucorrho?a, where there is no such remote and influential sympathy. 

Symptomatic leucorrhcea, as its name implies, being the consequence 
of other and distinct diseases, may be attributed to any causes which 
shall produce uterine or vaginal irritation. Amongst these must be 
mentioned relaxation, prolapsus, and the other displacements of the 
womb, polypi of various kinds, affecting the uterus, vagina, or urethra, 
hard or soft tumours of the reproductive organs, ascarides, a pessary, 
and other bodies intentionally introduced into the vagina. 

Pathology. — There can be no doubt that leucorrhcea owes its origin 
to two distinct and dissimilar conditions. The first, a state of hyper- 
emia or increased action of the vessels of the secretory surfaces, and 
the second, debility, either original or produced by the continuance of 
the former state. By some authors nearly all the cases are supposed 
to depend on weakness, excepting such only as are accompanied by 
symptoms of inflammatory action. There is truth in this opinion if 
the examples be included where the leucorrhcea having been of the 
first kind originally, has by its continuance terminated in the opposite 
state. Let it, however, be remembered, that it does not necessarily 
follow because the system generally is delicate, that the uterus and 
vagina must of necessity be in a state of anaemia. Local and long- 
continued inflammation often produces constitutional weakness, and 
certainly the progress of the malady, the irritation and pain, and the 
increased secretions, point to inflammation as one of its essential pri- 
mary conditions. Nor must we forget that delicacy often exists with- 
out leucorrhcea. Still, original or acquired feebleness of system may 
give increased efficacy to the various exciting causes of this prevalent 
malady. 

Probably in all the instances where the uterine lining membrane is 
implicated, particularly in those where leucorrhcea is vicarious of 
menstruation, the vessels eliminating the catamenial fluid furnish the 
morbid discharge. In the symptomatic forms, the pathology is neces- 
sarily different, as a displaced uterus, a prolapsed vagina, hard tu- 
mours, and various other structural growths and deviations, produce 
the disease. 

Diagnosis. — This is frequently difficult, and between some forms of 
the disease and gonorrhoea nearly impossible. Still in numerous in- 
stances a correct distinction may be drawn, and where difference of 
treatment is involved, it ought to be attempted. 

In mild leucorrhcea it may be assumed, that the muciparous glands 
at the entrance of the vagina and the lining membrane of the canal 
are alone affected. Where the symptoms are decidedly severe, the 
uterine lining membrane is often interested. The diagnosis will be 
aided by an inquiry into the following circumstances : If the dis- 



132 LEUCORRHCEA. 

charge was first observed after abortion or delivery; if it was prior 
to, or has partially or entirely superseded menstruation ; if there be 
much pain in the hypogastric or lumbar regions, with nausea and 
vomiting, or uncomfortable sensations about the stomach, liver, or 
head, these point to an affection of the uterus, rather than of the va- 
gina. With the latter, we know that the constitution sympathizes but 
little, while with the uterus, by means of the organic nervous system, 
its sympathy is most intimate. It has been proposed to use a piece of 
sponge as a local test, which is to be introduced into the vagina, so as 
to plug the os uteri, on going to bed ; and if, when it is removed in the 
morning, there be no more discharge adhering to it than would occur 
from the natural mucus of the canal, the discharge which takes place 
by day must be regarded as uterine. If, on the contrary, the sponge 
be thoroughly moistened, the vagina must be considered as implicated 
in the mischief. But it is evident that this test is not unexceptionable. 
If the discharge be uterine only, but excessive, the sponge will be much 
wetted with the absorption, the uterine cavity being so small in its nor- 
mal state, that it cannot contain more than a few drachms. If the 
vaginal surface be also secreting in excess, no satisfactory diagnosis 
can be thus made. Nor will an examination by the finger afford un- 
erring information ; as in merely vaginal leucorrhoea, if it be profuse 
and of long standing, there will be a similar relaxation and softening 
of the cervix, as is found where the uterine surface is affected, and in 
most instances of either form, the os will be open, or in at least a dila- 
table state. Thus we are compelled to depend on the indications pre- 
viously stated, 'except where we are permitted to use the speculum, the 
only certain means of diagnosis. The following account comprises 
the result of M. Marc d'Espine's researches with this instrument on 
the subject of leucorrhoea. They were extracted from the Arcbiv. 
Gen. de Med. for February, 1836. 

M. d'Espine notices its continuance during the menstrual intervals, 
and also its occurrence just before or just after the menstrual evacua- 
tion. The climate of the middle and north of France appears most 
favourable to its production, and women with very light or very dark 
hair seem most liable to it. The character of the constitution exercises 
very little influence. Out of nineteen women subject to whites habitu- 
ally, six were robust, nine were moderately strong, and four weakly. 

An examination with the speculum gave the following result in 193 
cases. In 23 the uterine orifice was found dry — in 40 there was just 
a drop of discharge in the orifice— in 130 the discharge was abundant. 
The orifice may be quite healthy — pale— red— or bright-red, and oc- 
casionally it was granulated and 'bloody. 

The following table will exhibit the character of the discharge and 
the state of the uterine orifice, in 111 cases. 

,. , Orifice healthy. Orif. reddish. Orif. deep-red and granulated. 
Aqueous discharge 7 3 | 

Albuminous transp. discharge .30 6 6 

Album, semi-transp. discharge, 

streaked blue, gray or yellow . 13 19 10 

Opaque discharge, streaked . . 3 7 6 

53 35 23 



LEUCORRHCEA. 133 

Doubtless where there is pregnancy with a sealed os, the leucor- 
rhcea, however severe, must be vaginal. 

From leucorrhoea, the consequence of structural or malignant dis- 
ease, the diagnosis will be made by the accompanying symptoms, and 
by examination of the vagina and rectum, not only by the finger, but 
by the speculum. • 

From inflammation of the glands in the interior of the cervix ; by 
the presence of the white creamy discharge ; and by the peculiar ten- 
derness of the cervix on pressure, the adjacent parts being quite sound. 

From fluids, which very rarely find an outlet through the vagina, 
after the bursting of an abscess or cyst in the ovary, uterus, or sur- 
rounding organs ; by previous indications, such as local pain, swelling, 
&c, which do not occur in leucorrhoea; by the suddenness of the 
escape, and often by some marked quality of the discharge, as its offen- 
sive odour and its colour, being often mixed with blood, and its extreme 
viscidity or acrimonious tenuity. 

From gonorrhoea the distinction is often difficult, and in some in- 
stances impossible. The characters of the individuals, and particularly 
of the husband, and the previous and present habits of both, if they 
be highly moral, will go far to negative suspicion. Even in doubtful 
cases, it must be remembered that leucorrhoea is sometimes purulent, 
and so far infectious, as to produce from the male urethra a discharge 
which, in its appearance and accompanying symptoms, is not easily 
distinguished from gonorrhoea. Generally the secretion in the male is 
mild, and there is but little of that excitement, heat, and ardor urinse 
so constantly attendant on the real infectious gonorrhoea. It is said, 
too, that it is quickly cured, and that it is rarely or never succeeded 
by gleet. These observations are in the main correct, but they still 
require some qualification. Where, by the speculum, erosions or chan- 
crous sores can be perceived on the os and cervix, the syphilitic cha- 
racter will be established. If, also, there be tumefaction of the in- 
o-uinal glands, pain during coition, and a discharge from the urethra, 
with a burning pain along its course, and tenderness and inflammation 
at its orifice, "gonorrhoea is probably present. Lisfranc says, "that it 
is very difficult to ascertain whether these white discharges are or are 
not contagious, whether they are or are not venereal. He thinks that 
a w T hite discharge may communicate the venereal disease, especially 
when the former is connected with small ulcerations of the vagina or 
urethra, a case more common than is usually thought, but which may 
be ascertained by examining with a glass those parts, the slightest ero- 
sions of which easily escape the naked eye." (Vide Lectures published 
in the Lancet, Nov. 30, 1833.) I presume this singular statement is 
, not intended to convey the idea, that the venereal disease can be com- 
municated by common and unspecific ulcerations, merely because 
they happen to exist on the cervix uteri ; and still, if less than this is 
meant, there is little if any point in the passage ; because the state- 
ment is a mere truism, that syphilitic erosions or chancres can produce 
the syphilitic disease. The perplexity, therefore, of these cases, is 
fully admitted ; and it will often happen, that where we are most anx- 
ious to arrive at a positive conclusion, we shall be least able to do 



134 LEUCOKRHCEA. 

so. At all events, it behooves the practitioner to be extremely tena- 
cious of the reputation and happiness of parties thus circumstanced. 
It is always his duty to cure the disease, but rarely to venture upon an 
exposition of its nature. If he can positively affirm that it is of simple 
origin, let him do so, if suspicion has been aroused ; if not, it is better 
to avoid an}* distinct allusion to the matter. One thing is quite true, 
that in women of indisputable purity, leucorrhoea is sometimes so acri- 
monious, as not unfrequently to produce discharge and abrasion in the 
husband ; and on one or two occasions, after abortion, I am almost con- 
fident, that eruptions and decided ulceration have been among the 
results of intercourse. In these examples the shadow of suspicion did 
not rest on the female. 

Prognosis or terminations of leucorrhoea. 

Acute leucorrhoea, if treated promptly, is usually of short duration. 
The symptoms gradually subside, and the tone of the parts is regained. 
If, therefore, there is a leucophlegmatic habit, and a constant excess 
of moisture about the genital apparatus, it is not improbable that an 
inflammatory attack, under such circumstances, may glide into the 
chronic form, and may long continue. Some females, indeed, except 
when in unusually good health, seem never to be free from habitual 
leucorrhoea ; nor does it appear seriously to affect them. But there are 
cases, where the discharge is so profuse and protracted, that the same 
results are realised as in excessive menorrhagia. There is a quick 
and feeble pulse, a cadaverous countenance, impaired appetite, and 
emaciation. If the patient be married (vide case), sterility is not an 
uncommon consequence ; and if single, chlorosis and amenorrhcea, and 
possibly dropsy or phthisis, may supervene. I do not affirm these 
greater evils to be the frequent sequel of the disease ; but the practi- 
tioner should be on his guard, more particularly where, in the un- 
married, emaciation, amenorrhcea, and chlorosis exist. A cough, 
fever, morning perspiration, and pulmonary affection, may soon fol- 
low. 

Treatment. — This must of necessity be different. The various forms 
of the malady differ so widely from each other in degree, that while 
in the slighter cases scarcely any treatment at all is required, in the 
inveterate it is often most puzzling to find any remedy. Thus the 
mild form easily yields, the inveterate is cured with great difficulty ; 
and the symptomatic leucorrhoea cannot be restrained till the removal 
of the affection, if that be possible, of which it forms a part. But 
to be more precise : In ordinary cases, where there is only hyperaemia 
or simple vascular injection of the secretory membrane, and where 
the discharge, although increased in quantity, still retains its trans- 
parent mucous character, — rest, abstinence from intercourse, if mar- 
ried, animal food and wine, mild aperients, and the employment, as a 
wash, of the Liq. Plumb. C, or the Liq. Alumen. C, or the tepid 
poppy water, will usually, in the course of a few days or a week, cure 
the disease. 

In the inflammatory form, which comparatively we do not often 
see, where the secretion has become purulent, where the pulse is quick, 
full, or hard; where there is heat, increased action, and inflammatory 



LEUCORRHCEA. 135 

congestion of the secretory surfaces, slight swelling of the genitals, and 
pains in the loins and hypogastric region, the antiphlogistic treatment 
must be at once commenced. Blood may be drawn from the arm in 
moderate quantity, or from the loins by cupping. Leeches to the 
hypogastrium, groins 3 or perineum, must be promptly employed ; and if, 
by a vaginal examination, the cervix shall be found swolien, shining, 
red, and tender, leeches, or what are much better, scarifications, may 
be used. I have now several times scarified, not punctured the neck 
of the uterus by a common lancet, mounted on a piece of whalebone, 
with marked benefit. The pain of the incision is most trifling ; there 
is no ulceration nor suffering afterwards, and in twenty-four hours, 
the cervix generally seems to be entirely free from congestion. In the 
winter of 1839, I was asked by the late Mr. Fenner to visit a patient 
of his at Islington, suffering from inflammatory leucorrhcea. She had 
not been confined more than two months ; her own reputation, and 
that of her husband, were above all suspicion ; the severity of the pain 
in micturition, and the profusion and acrimony of the discharge, 
would have induced the belief that it was gonorrhoea. An examina- 
tion by the speculum showed that the cervix was congested, red, and 
extremely tender; but there was no discharge from the urethra, nor 
any swelling of the inguinal glands ; aided by the speculum tube, the 
cervix was scarified, and at leest four or five ounces of blood were 
abstracted, the operation not lasting more than a quarter of an hour. 
The hip-bath, as advised at page 86, mild aperients, spare diet, sa- 
lines, and occasionally narcotics, will be required. Astringents are 
not included in this enumeration, and if they are used during the first 
few days of the disease, while the inflammatory stage continues, or 
before the discharge has become thinner and more abundant, pain and 
aggravation of symptoms will often ensue. I know there are cases 
easily cured by the compound alum injection, or some spirituous 
lotion only. In such, the affection is probably the common and mild, 
not the inflammatory leucorrhcea ; or if it be, and a cure is obtained, 
the patient and the practitioner will not censure this empirical plan, 
nor trouble themselves about the precise nature of the affection. If 
there be swelling of the labia, or of the parts within, redness, heat, 
tenderness, and throbbing, and pain on examination, with a purulent 
discharge, there is inflammation, and the soothing, not the astringent 
plan ought first to be tried. These acute symptoms, however, soon 
subside, but the excessive discharge continues ; and at this point the use 
of injections, regarded by many as the specific treatment for leucor- 
rhcea, must be commenced. For this purpose the various stimulants 
and astringents are employed, and often by sponging the parts exter- 
nally, and within the genital fissure, but more frequently by throwing 
into the vagina, several times daily, two or three ounces (following 
the directions given at page 108), aided by stomachics or tonics, mild 
aperients and rest, this unpleasant affection is cured. Generally the 
injections are cold, but occasionally the discharge is increased, and 
the inflammatory symptoms are re-produced by cold in any form. I 
have known many patients cured by tepid, and two by almost hot in- 
jections. Dr. Gooch (at page 35 of his Compendium) says, " that the 



136 LEUCORRHCEA. 

treatment of leucorrhcea is to a great extent empirical. Cold astrin- 
gents, among the rational practitioners, are in the most general use ; 
but tepid ones are often equally beneficial. Practitioners have ex- 
hausted all the colli astringent remedies, and then, having recourse to te- 
pid ones, the patient has been cured immediately. The liquor plumb, 
acetat. is now used at the Middlesex Hospital, tepid, and with gene- 
ral success." The various formulas will be hereafter mentioned. In 
this way examples of the inflammatory form are cured ; but thus far 
it is presumed, that they are not very severe, nor that there is any- 
thing to prevent the beneficial operation of medicines, either in the 
constitution or in the habits of the patient. But we do not always pos- 
sess these advantages. Sometimes, where the best means have been 
long and judiciously employed, the leucorrhcea continues, and the 
health declines. If the discharge be only small in quantity, and if the 
patient has been originally robust, months and even years may elapse 
without any serious results ; but they come at last. I have often won- 
dered to find the pallor, anaemia, and Other indications of debility, so 
extreme, where the discharge was scarcely more than by drops, al- 
though it had been more excessive. These examples remind us of 
passive menorrhagia, where there is a continual sanguineous draining 
from the uterus, attended by a cadaverous countenance, weak pulse, 
coldness of the extremities, and excessive nervousness. Indeed, these 
cases are not only similar in their nature, but they are almost invari- 
ably benefited, and sometimes cured, by one peculiar remedy, viz., the 
injection of three or four ounces of tepid, or (after a time) cold water, 
jnto the rectum, night and morning. Sometimes the effects of chronic 
leucorrhcea are so distressing, the discharge so excessive, and the 
cure apparently so distant, that not only the patient, but the practi- 
tioner also, inquires, what further treatment can be adopted, and on 
w T hat circumstances does this want of benefit depend ? In some in- 
stances, there is no doubt, that the delay arises from the difficulty of 
restoring to the secretory membranes their healthy action. Mr. Hun-, 
ter fixed attention on this point, by the following remark, that " a 
gleet seems to take its rise from a habit of action which the parts have 
contracted ; and as they have no disposition to lay aside this action, 
it is, of course, continued." Thus a vaginal discharge may be per- 
petuated by a " habit of action," most difficult to alter, but at the same 
time, satisfactorily explaining the pathology of passive or habitual leu- 
corrhcea. Protraction may also depend on specific or organic dis- 
ease, such as gonorrhoea, hard or sub-mucous tumours, ulcerated car- 
cinoma, polypi, cauliflower excrescences, &c. The reply then, to 
the question, what further treatment is to be employed? will depend 
on the results of examination by the finger or speculum, as these will 
furnish the best answer to the inquiry, what is it that prevents the 
cure ? If the existence of structural maladies be discovered, the at- 
tention will be directed to these as the source of the local symptoms, 
for leucorrhcea is then only symptomatic of these graver diseases. 
But if, so far as can be ascertained, the individual is free from any 
specific or organic affection, recourse must then be had either to fresh 
remedies, or the treatment already adopted must be differently and 



LEUCORRH(EA. 137 

more perseveringly pursued. English practitioners do not frequently 
examine per vaginam in leucorrhcea ; although in the majority of cases 
such an inquiry may be dispensed with, in dubious instances it is cer- 
tainly requisite. So long as the discharge is muciform, even if it be 
excessive, without smell and not sanguineous, it may be presumed to 
be functional ; but where, having long retained these properties, it has 
become acrimonious and offensive, watery and greenish, or brown, 
like the grounds of coffee, or decidedly streaked and mingled with 
blood, there is strong reason for a different opinion, and an examina- 
tion is absolutely essential. Injections of green tea, solutions of alum, 
the sulphates of zinc and copper, iodine, sulphate or tartrate of iron, 
and the carbonates of soda and ammonia, decoctions of bark, log- 
wood, the ergot and catechu, and others (vide formulae), may all be 
employed. Nor must it be forgotten that each of these, good though 
it be, soon loses its effect. I have cured many cases of passive leu- 
corrhoea more quickly than I should otherwise have done, by acting 
on this suggestion : a week being often long enough to wear out the . 
good effects of one injection. In the employment of measures acting 
thus locally on the secretory organs, the intention is to convert a mor- 
bid into a healthy function, and of course constitutional means, such 
as good air and diet, iron, quinine and chalybeate waters, with a re- 
gulated system of aperients, are not to be excluded. Both classes of 
agents may be in operation at the same time, without determining, 
what is often difficult to decide, whether the leucorrhoea be a primary 
or secondary affection ; whether, in fact, it has arisen from constitu- 
tional delicacy, or whether the constitutional weakness is the sequel of 
the local disease. Where the discharge is habitual and inveterate, and 
where, without disorganization of structure, the secreting surfaces have 
taken on a permanently unhealthy and disordered action, the nitrate of 
silver surpasses all other remedies in its restorative power. Its benefi- 
cial influence has been fully tested in affections of the mucous tissues 
of the mouth and throat, and a similar good effect will accrue from its 
use in chronic and inveterate leucorrhcea. Its exhibition will be ex- 
plained hereafter (vide formulae). To Dr. Jewel the profession is 
indebted for a succinct and comprehensive account of its properties. 
Through the medium of the great sympathetic nerve, and by continuity, 
the reproductive or sexual are intimately connected with the urinary 
organs, and hence have been suggested copaiba, turpentine, cubebs, 
cantharides, and the tinct. benzoina comp. (vide formulae), for the treat- 
ment of the chronic and inveterate form. Turpentine and cantharides 
I have given, often advantageously, and a good many times w T ith cura- 
tive effect. The latter is the great remedy of Dr. Dewees ; and, be- 
ginning with thirty drops in sugared water, three times daily, he does 
not hesitate to mount up to a dose of two hundred, three times in the 
twenty-four hours. He is careful, if there be plethora, that it shall be 
removed prior to giving the tincture. 

" We cause the patient," he informs us, " to be well purged ; con- 
fine her to a milk and vegetable diet, and sometimes order her to lose 
blood ; when the pulse is sufficiently reduced by these means, or if the 
pulse be in a proper condition without them, we commence the cantha- 



138 LEUCORRH(EA. 

rides, &c." It need scarcely be added, by way of caution, that if 
strangury appear, the tincture is to be left off. u Should the complaint 
withstand the first strangury, we are not discouraged, but re-commence 
the remedy at the original dose of thirty drops, and increase it as be- 
fore until a difficulty in making water is again experienced ; it rarely, 
however, withstands the second irritation of the bladder." In hospital, 
and in private practice, I have secured these conditions ; but I cannot 
report, as its author does, "that when properly conducted, or suffi- 
ciently persevered in, it rarely fails to effect a cure." Still, my con- 
fidence in this practitioner is so great, that I am anxious his remedy 
should be extensively tried : — in other hands it may be more successful 
than in mine. 

Attention to the general health cannot be neglected without detri- 
ment to the patient. Lately, I saw a case where the discharge, which 
had been for weeks excessive, was restrained by giving five or six 
doses of blue pill, followed by an aperient of senna and salts ; the 
first motions were highly offensive and scybalous ; afterwards they be- 
came healthy, and with no other treatment than ablution, and a re- 
moval into pure, dry, and mild air, and the adoption of good diet and 
exercise, by which the function of the skin was restored, the cure was 
completed. 

If the reader will turn to page 30 of this work, he will find in that 
and the succeeding pages, directions relative to the health of anemia- 
ted patients, which may be advantageously followed in chronic leucor- 
rhoea. It is scarcely necessary to state, that menstrual irregularity is 
one of the frequent consequences of the disease when protracted. 
Leucorrhoea may, indeed, become vicarious of menstruation altogether 
(vide page 77) ; and certainly, although amenorrhcea induces leucor- 
rhoea, the converse of this position is equally true. Whenever, then, 
the general health is so far impaired by excessive discharge, as se- 
riously to have deranged the catamenial function, constitutional as well 
as local treatment must be pursued. A sea voyage, travelling abroad, 
the air of the sea-coast, foreign and domestic chalybeate spas and 
iron, constant exercise out-of-doors, living, in fact, in the open air, are 
the measures on which we must principally rely. The use of wine 
and spirituous liquors, strong tea and coffee, is recommended in ha- 
bitual or passive leucorrhcea. Doubtless such advice requires strict 
limitation, but still, in certain districts, and controlled by medical au- 
thority, it is beneficial. I recollect many years ago an old practitioner 
in the fenny and damp part of Lincolnshire, who said that the disease 
was almost endemic in his neighbourhood during certain parts of the 
year, and that he combated, and often cured it, by bark, wine, gin, tea, 
and coffee. In Belgium and Holland, and round Berlin, the atmos- 
phere is loaded with moisture, and it is common to attempt the cure 
of leucorrhcea, which is very prevalent, by spirituous liquors, tea, and 
flannel clothing. Solid animal food may be eaten twice in the day, 
and if the digestive powers are much impaired, hot water, with a third 
or fourth part of brandy or rum, may be the dinner beverage. But, 
after what has been said at page 30, I need only refer to the directions 
there given. A patient, suffering from habitual leucorrhoea without 



LEUCORRH(EA. 139 

organic disease, should not sleep on a soft bed, nor frequent heated 
rooms and crowded assemblies. The excitement of music, the theatre, 
and late hours, should be exchanged for country air and exercise, mode- 
rate riding on horseback, and the simpler habits and scenes of rural life. 
In these cases, almost everything depends on the improvement of the 
general health, and this cannot be accomplished without attention to 
the chylopoietic organs. Let healthy digestion be restored, and the 
leucorrhcea will gradually disappear. It is not always safe to cure 
an inveterate leucorrhcea, without increasing for a time the action of 
the liver and the intestines, or putting the patient on a spare diet. This 
is particularly important where the discharge first appeared on the 
suppression of some customary evacuation, as, for example, where men- 
struation has become sparing after previous excfess, or where an erup- 
tion having long existed, has at once or gradually disappeared. In 
these instances, some moderate drain is often necessary. Without it 
plethora, and its injurious consequences, may occur. An issue or seton 
ought occasionally to precede any curative attempt. In the young 
and middle-aged, spare diet, purging, and exercise will mostly suffice; 
but in women of full habit, addicted to the pleasures of the table, this 
more decided drain is often 'required. At a more advanced age, when 
congestions in the different organs are probable, and where the patients 
are strumous and feeble, peculiar watchfulness is requisite. After the 
cure of habitual leucorrhcea, ablutions of cold water, at least, if not 
injections to the vagina, should be daily practised ; avoiding their use 
for a few days before and subsequent to menstruation. 

In Dr. Balbirnie's digest of the practice in Female Diseases, of 
several eminent French physicians — a book deserving attentive perusal, 
the fears I have expressed of injecting the uterine cavity are said to be, 
in the great majority of cases, "totally unfounded, and the mere rem- 
nant of ancient prejudice." M. Lisfranc first injects simply fresh water, 
then decoctions, or astringent injections or styptics, the strength of which 
is to be increased by the addition of a few drops of concentrated acid. 
? A gum-elastic tube, introduced with circumspection, serves as a 
means for conducting the injected fluid, and we are thus enabled to 
cure white discharges which obstinately resist every other method." — 
(Vide Lectures in the Lancet, Nov. 30, 1833.) I shall append to 
this chapter one or two cases, occurring in the practice of M. Tealier, 
where injections of soot and water into the uterine cavity were pro- 
ductive of benefit, without pain or any apparent evidences of hyste- 
ritis. It is right thus to contrast the contradictory results of a similar 
treatment. Further experiments, which these examples of success 
may justify, may establish a correct deduction. In the French hospital 
cases, reported by Dr. Balbirnie, "narcotic injections" were ordered 
by the physician; and as immediately afterwards especial mention is 
made of "uterine injections" in the private cases of M. Tealier, it is 
fair to infer, that the narcotic injections referred to above, were merely 
vaginal, thus establishing the fact, that throwing fluids into the cavity 
of the womb is by no means a general but a rare treatment. Further 
on, indeed, M. Lisfranc says, " that sometimes these uterine injections 



240 LEUCORRH(EA. 

stop the discharge suddenly, as in the male, or they act more slowly, 
in general requiring twenty or twenty-five days. On other occasions" 
(and these, I fancy, are not unfrequent) "they convert the chronic 
inflammation into an acute one" (an event replete with danger, where 
the uterine mucous surface is its seat); "hence the treatment must be 
modified to the case, and usually twenty-five to thirty days are suffi- 
cient for a perfect cure." "As exceptions, there are two cases in 
which we should proceed with more reserve, viz., when these dis- 
charges are very ancient" (the examples in which, by-the-by in Eng- 
land, such a remedy is generally thought of) "then they become ha- 
bitual and necessary to the economy: and it is frequently impossible 
to supply their place" (this is a wise and extensive interdiction of 
uterine injections), "and imprudent to attempt it — more especially if 
the woman be old, feeble, or have any tendency to scrofula. Intermit- 
tent discharges also require the same precaution, with respect to their 
suppression, as uterine flooding." 

Inflammation of the cervix uteri. — As this affection is confined to the 
glandular part of the uterus, and as it is attended by a peculiar dis- 
charge which rarely forms a part of the common leucorrhceal secre- 
tion,~it is entitled to distinct consideration; It is not always easy to 
distinguish it from inflammation of the surrounding parts, particu- 
larly when, having ceased to be an acute, it has become a chronic 
malady. Here the white opaque secretion, its distinctive sign, will be 
partially, if not entirely, lost, by its mixture with the thinner and more 
transparent secretions. In addition also, the local pain and tender- 
ness on pressure will be so much less than in the inflammatory stage, 
that the peculiar characters of the malady will be nearly destroyed. 
In recent and marked cases, its diagnosis is easy. Sir Charles Clarke 
is entitled to the praise of having first described the symptoms and 
treatment. Judging from the record of cases amongst the in and out- 
patients at Guy's, as well as from private practice, I cannot regard it 
as a very common disease. Many times, from the pain which patients 
in the ward have complained of low down about the sacrum and coc- 
cyx, and deeply seated behind the pubis, I have thought that there 
must have been inflammation of the cervix ; and yet on examination, 
although the finger has been covered by a white secretion, there has 
been no acute suffering from pressure on the neck of the uterus. Out 
of nearly one thousand cases of sexual disease, treated at Guy's, I find 
inflammation of the os and cervix has happened only twenty times. 
It rarely occurs in single females, or before twenty, and is most com- 
mon between this age and the period of catamenial decline. It is not 
dependent on peculiarity of constitution — the plethoric and robust 
being as frequently its subjects, as the delicate and irritable. 1 have 
several times observed it soon after marriage. Its pathognomonic symp- 
toms are the opaque white discharge and pains behind the pubis, and 
at the lowest part of the back and sacrum, aggravated by the mus- 
cular efforts necessary for the evacuation of the bowels and the 
bladder ; in short, by any circumstance which causes pressure cen- 
trally in the pelvis. The constitution is rarely affected, if judicious 



LEUCORRH(EA. 141 

treatment has been early adopted. Where, however, there has been 
protracted neglect, it will probably have passed into a chronic state, 
and, in connexion with inveterate leucorrhoea, may have induced 
excessive anaemia. These symptoms — and, if married, pain during in- 
tercourse — first excite attention ; their continuance, and, as concomi- 
tants, irritability of the bladder and rectum, constitute the disease. Ge- 
nerally menstruation is not deranged ; occasionally, however, there 
is dysmenorrhea or a scanty catamenial flow. Sometimes recovery 
takes place without any treatment ; the symptoms gradually disappear, 
and the glandular structure again becomes sound. At other times 
the malady continues, notwithstanding the treatment ; and some au- 
thors suppose, that from this chronic inflammatory action, tubercular 
deposit and cancerous disease may have their origin ; but such se- 
rious results, probably, never occur, except where there is a latent 
tendency to structural and malignant disease. In that case it is easy 
to understand how repeated inflammation may induce morbid activity. 

Causes. — Circumstances either of a constitutional or local kind, 
which augment irritability, and produce in the cervix increased action. 
Cold, inordinate exertion, either physical, sexual, or mental, highly 
seasoned food, late hours, and excitement, and amenorrhcea suddenly 
induced. 

Diagnosis. — The local pain (pressure on the cervix producing it, 
while similar pressure on the immediately contiguous vagina, or on 
the body of the uterus, is borne without any suffering), and the white 
opaque discharge, enable the practitioner to form a correct opinion of 
the disease. In reference to the latter I may add, that it differs widely 
from the transparent colourless mucus of common leucorrhoea, and is 
not likely to be confounded with the watery, or purulent secretions, so 
frequently occurring in mixed and symptomatic cases. 

Sir 'Charles Clarke characterizes the discharge " as opaque, and 
perfectly white." This is its usual colour, but in undeniable examples 
I have seen it of gray tint. He further says, " that it resembles, in 
consistence, a mixture of starch and water made without heat, or thin 
cream. It is easily washed from the finger after an examination ; and 
it is capable of being diffused through water, rendering it turbid." Of 
the latter part of the statement there can be no doubt, and the facility 
of mixture with water, certainly constitutes a ready and true diagnosis. 
Let it, however, be remembered, that this creamy discharge is rarely 
copious and free from admixture, except on rising from bed in the 
morning, the time which ought to be chosen for the vaginal exami- 
nation. 

Treatment. — The abstraction of blood, in the more serious attacks, 
is a primary measure. And as the best methods of doing this are 
pointed out at pages 87 and 88, the reader must refer to this part of 
the work, where he will also find directions for the bath and injections, 
which may be beneficially followed where the inflammation is not so 
severe as to require the loss of blood. The poppy hip-bath used for 
an hour, twice a-day, soothes the pain and irritation better than any 
other remedy ; and where this cannot be obtained, half a pint of warm 
water, or gruel, starch water, or poppy tea, may be thrown into the va- 
10 



142 LEUCORRHffiA. 

gina several times daily— the prescribed precautions being taken to pre- 
vent its immediate return. As aperients, castor oil, or any of the mild 
forms prescribed in chapter 5, may be employed. Sometimes there 
is so much irritation about the bladder, that an opiate of ten drops, two 
or three times daily, of the mist, morphias acetatis (vide page 97), 
may be administered, or an opium, or a belladonna suppository may 
be used. It is occasionally necessary to empty the bladder by the 
catheter ; and rest in the recumbent position and spare and unirritating 
diet must be adopted. 

Case 34. 

It is unnecessary to narrate any cases of common leucorrhcea, 
either of the mild or acute kind, as these are so numerous as to be 
familiar to all. 



INVETERATE LEUCORRHCEA. 

July 10th, 1835. Mrs. J. , aged 26, residing near Guy's Hospital, has been 

married six years, and has borne three children. Prior to her first confinement — 
immediately, indeed, after marriage — she had leucorrhcea ; but as it was attributed 
to the excitement of pregnancy, and ceased soon after delivery, no treatment was 
adopted. During both the subsequent pregnancies the discharge returned, and dis- 
appeared after recovery. She imputes the present attack to over-nursing, having 
suckled her last infant nearly sixteen months. The weaning occurred in January, 
1834, and since this time, now a year and a half, she has never been free from ex- 
cessive discharge. Prior to the lengthened nursing she was remarkably healthy, 
"embonpoint," and active; but for the last nine months her weakness has been ex- 
treme. She is anemiated and pallid, emaciated, and incapable of any exertion. She 
has lost her former animation, and sits or lies nearly the whole day on the sofa. 
Pulse 94, and feeble, skin cool and clammy ; urine scanty, and of straw colour; ap- 
petite most capricious, and frequent vomiting after taking food. Sleeps well at night, 
and would do so nearly all day, if she were not frequently roused by her mother and 
children. Cough, pain in the side, and morning perspiration are absent, and none of 
her family have died of phthisis. The legs are edematous, and the skin of the face 
and eyelids is extended and flabby. On the whole, there is more exhaustion, more 
complete prostration, than I have ever before witnessed as the consequence of leucor- 
rhcea. On inquiry about the treatment, I found that many remedies had been tried, 
and although injections had been carefully used she had frustrated their beneficial 
effects, by always (day and night) wearing two thick napkins. Thus the generative 
organs were constantly heated by the thickness of the covering, and increased dis- 
charge was the result. It was with difficulty she was persuaded to use any further 
means, she was so determinately convinced that nothing could do her any good. She 
consented, however, to take the muriated tincture of iron, good diet, and ale, to use 
nitrate of silver injection three times daily, and, above all, to leave off the napkins. 
The discharge was usually thin and watery; sometimes viscid, and occasionally, for 
a few weeks together, purulent. It had, on several occasions, been streaked with 
blood ; but there had never been any offensive odour. She had for many weeks ab- 
stained from intercourse. I was curious to ascertain its quantity, and as it was quite 
necessary to use six napkins in the twenty-four hours, she must, at least, have lost 
several ounces daily. It is not, therefore, at all surprising after so protracted a drain, 
that her constitutional power was exceedingly impaired. Menstruation occurred 
every month, but so scantily, and so slightly sanguineous, that the leucorrhcea might 
justly have been considered as vicarious of the function. On examination, internally, 
by the finger, the vagina was found to be capacious, and so relaxed that there were 
many folds partially filling up its canal, and a thin secretion bathed its entire surface. 
The cervix was larger, but not tender, the os patulous with thickened edges, and the 



LEUCORRHOEA. 143 

whole of the parts exceedingly moist and soft. The body of the uterus, examined 
by the rectum as well as by the vagina, appeared more voluminous than natural, and 
approached nearly to the os externum. I could not discover any ulceration, although 
at the upper and posterior part of the vagina the surface was rather rough, uneven 
and pulpy. 

It would be tedious to narrate, day by day, or even week by week, the effects of 
the remedies. The principal benefit seemed to be derived from the various prepa- 
rations of iron, and the frequent use of injections, particularly of the nitrate of silver. 
These had been employed by her previous attendant ; but as he had seen her only at 
distant intervals, their use was not steadily adhered to. I was more fortunate, as I 
visited her very frequently on my way to Guy's, and insisted, as the condition of my 
attendance, that the treatment should be strictly pursued. At one time we were 
compelled to give up the injections for a few days, as they produced soreness, and she 
was tired of their use. At another, the iron was temporarily laid aside, quinine and 
gentian, or zinc and hop, being substituted. The local salt shower-bath over the ab- 
domen and hips was extremely beneficial, and she expressed great satisfaction on 
finding that she was gradually acquiring tone and strength from its daily use. At 
first it was employed tepid, and subsequently quite cold ; and she was rubbed dry 
'afterwards by towels impregnated with bay-salt. The lower part of the body ac- 
quired warmth by these frictions, and her whole appearance began to improve. The 
injection was ultimately used, at 60 grains of the nitrate to ^xvj. of distilled water. 
The napkins were entirely and most beneficially abandoned, — frequent ablutions and 
clean linen being their substitutes. In chronic and inveterate leucorrhoaa the wear- 
ing a protection of this kind, and sometimes a pad, which is still worse, perpetuates 
the disease. And now, in every case, 1 am particular in my inquiries on this point. 
At the expiration of eight months this patient had menstruated healthily three times, 
and she had regained much of her former health. She visited Brighton for several 
weeks, and in about twelve months from my first seeing her, she had perfectly reco- 
vered. I hear that she has since borne another child. 

This is an instructive, because it is not a very rare case of aggra- 
vated leucorrhoea. Over-lactation and frequent pregnancy are almost 
sure, sooner or later, to be succeeded by excessive mucous secretion. 
Whether it shall be protracted to exhaustion, will greatly depend on 
the attention and influence of the practitioner. If he regard it as a 
matter of little moment, it will be allowed to persist, and eventually, 
similar results to those pointed out, will occur ; if, on the contrary, he 
have sufficient weight to convince the patient of her situation and its 
certain consequences if the discharge continue, then remedies will be 
promptly and efficaciously administered, and the disease will be either 
cured or relieved. 



Case 35. 

chronic leucorrhoea, attended by accumulations of purulent fluid. 

August, 1835. Mrs. , set. 38, a widow, and formerly an out-patient of • 

Guy's, was sent to me by Mr. Morgan, one of the surgeons. The history of the case 
is as follows : — She has, up to the commencement of the disease (nearly three years 
since), enjoyed excellent health. As a girl she was always vigorous, menstruated 
regularly, and was capable of great exertion. Subsequent to her marriage, in her 
twenty-fourth year, she was robust and plethoric, having children quickly, nursing 
them without difficulty, and improving in strength. She has now (1835) been a 
widow four years, and for the last three, has suffered from leucorrhoea. When first 
noticed, it occurred a few days before menstruation, and was not present again, till the 
return of the catamenia. It was so slight, that no means were used. Subsequentl} 1- , 
however, it continued throughout the month, and soon became excessive and acrime- 



144 LEUCORRHCEA. 

nioas. Occasionally it has been purulent, often mueo-puruient, and slightly odorous. 
In July, 1834, the discharge began to lessen in quantity and became thicker, to use 
her own words, "like matter." In a few days more, the leucorrhcea seemed en- 
tirely to have disappeared, bat not satisfactorily, as there was pain and fulness about 
the lower part of ihe belly, and especially about the neck of the womb, She had 
frequent calls to empty ibe bladder, there was ajdor orina?, and feelings of tension 
and weight within the pelvic cavity. The greater number of these occurrences 
was entirely new; for although she had frequently, when the discharge was puru- 
lent, suffered from vaginal irritation, heat, and pain, yet the symptoms just described 
were so different, that her attention was painfully excited. The surgeon then in at- 
tendance crave saline aperients, enjoined rest and spare diet, and recommended the 
■ warm hip-bath. On one occasion, a few weeks afterwards, when she was getting out 
of bed, she felt something suddenly give way within her, and there immediately es- 
caped from the vagina a quantity of offensive matter. She fainted, but was quite re- 
lieved The discharge continued purulent for a week, when the usual thin and mu- 
cous leucorrhcea returned. This process had been repeated several times prior to my 
first visit, August 10, 1835. She was then recovering from one of these escapes of 
purulent matter, and was feeble and altogether ill. Tonics, good diet, porter and 
wine were allowed j and in a few weeks the secretion had again become muco-puru- 
lent, but more excessive than formerly. At this period I examined, but there was no 
trace of altered structure. The os was more than usually patulous, and the whole ot 
the parts within reach of the finger were softened, probably by the constant dis- 
charges. In a little more than three months (Nov. 20, 1835), menstruation having 
beerTsuspended eicrbt weeks, re-accumulation again took place, and on examination, 
I was struck with = the increased bulk of the uterus. The cervix was tender to the 
touch, and the os was more closed than natural ; still, at the lower (whatever it might 
have been at the upper part of the channel of the cervix), it was not completely oc- 
cluded. There was, however, a firm, tense condition of the neck, as well as of the 
body of the womb, and the vagina was rather hot, although still moist and painful on 
pressure. There was considerable febrile excitement, and the patient was in bed. A 
few days afterwards the gush occurred, and by measure, it was ascertained, that seven 
ounces of fluid, possessing all the characters of true pus, not at all streaked with 
blood, had escaped- Twice afterwards this series of morbid actions was gone 
through, and on one occasion I was present when the matter escaped. It amounted 
to half a pint, and was certainly fetid. Her general health had improved, and the 
leucorrhcea in the intervals had slightly diminished. Iron in various forms and doses 
had been given, and I once pushed the blue pill sufficiently far to affect the gums, 
aentle salivation being kept up for several weeks. The nitrate of silver in solution 
had appeared sometimes as though it would entirely cure the affection, but the dis- 
charge again and frequently returned. Under these circumstances, I proposed the 
injection of the uterus. It was carefully done, by throwing in some portion of an 
ounce of warm water, with three grains of the sulphate of zinc. There were no imme- 
diate effects ; but in about six or seven hours, there were agonising pain in the ute- 
rine region and internally, tenderness on pressure nearly over the whole abdomen, 
but especially at its lowest part; a quick, hard pulse; and in fact all the symptoms 
of hysteritis. The measures described at page 120 were pursued ; but I was so fear- 
ful of an unfavourable result, that fifteen ounces of blood were abstracted, calomel and 
colocynth purges, and subsequently a full opiate, were given. After these measures 
the symptoms slowly subsided, and I had the satisfaction to find, in two or three 
weeks, that she had scarcely any remnant of the disease. This apparent cure was but 
of short duration. The same discharges again returned, and she left town for the 
sea-side. She resided there many weeks,, was considerably improved, and married. 
Pregnancy quickly occurred, and when I last heard of her, she had not suffered any 
return of this distressing malady. 



L£UCORRH(EA. 145 

Case 36. 

LEUCORRHCEA, ACCOMPANIED WITH PURULENT DISCHARGE. 
REPORTED BY DR. JOSEPH RIDGE. 

Marianne B , aged 19, of florid complexion, ordinary stature, and sanguine- 
ous temperament, was admitted in July, 1836, into Petersham Ward. She had been 
in service, and had enjoyed good health until eleven weeks since, when she began to 
complain of uneasiness in the hypogastric region, with severe pain in the right groin, 
increased towards night. This was accompanied with a thick yellow, and very fetid 
vaginal discharge, which has continued up to the present time. The catamenia have 
not been arrested ; and they appeared a fortnight before admission. 

Her general health has suffered : She feels weak, and indisposed to exertion. 
There is a profuse purulent secretion, which comes on at intervals, especially after 
exertion. On getting out of bed, or in endeavoring to evacuate the bladder or rec- 
tum, it passes per vaginam, by gushes, being preceded by a cessation for some hours. 
Occasionally, it continues for two or three days together ; and then ceases, until its 
accumulation is relieved by a sudden flow. She has lumbar pain, and occasionally 
a distressing sense of fulness and bearing down in the uterine region. Sometimes 
the pains are severe and lancinating, extending to the pubes and gxoins: bowels cos- 
tive: tongue slightly furred : pulse rather full, and moderate. 

These symptoms continued for several weeks, with but partial amelioration. The 
purulent secretion was, at intervals, diminished : but soon afterwards recurred, in equal 
quantity. She passed over two catamenial periods ; and the discharge appeared to 
be intimately mixed with the sanguineous flow. Some shreds of membrane were dis- 
covered, being preceded by more than usual pain. 

Tbe treatment consisted in the exhibition of laxatives, with occasional topical 
bleeding, and sedatives to allay constitutional irritation. An opium suppository was 
used, with a belladonna plaster to the loins. Injections of an astringent kind, va- 
riously modified, with the hip-bath, were employed, but with little advantage. 

The obstinacy of the disease, and the marked debility accompanying it, determined 
Dr. Ashwell to inject the cavity of the uterus with tepid water. This was effected 
by introducing a gum-elasfeic eatheter with an open mouth, the edges being smooth, 
within the cervix, and propelling the fluid through its tube. Considerable pain over 
the pubes followed, which was relieved by anodyne fomentations. The discharge 
greatly abated, and a second injection was ordered. This was followed by more se- 
vere symptoms, and marked evidence of hysteritis ; which was reljeved by bleeding, 
both general and local, purgatives, fomentations, and a strict antiphlogistic regimen. 
1 he discharge ceased with the cure of the hysterias ; and is a few weeks she was 
presented, feeling quite well. 

I was not prepared for so alarming an attack of inflammation, as 
the consequence of the injection merely of warm water ; although 
in several instances, and especially in the somewhat similar one 
already related, hysteritis of marked severity followed the use of a 
weak solution of the sulphate of zinc. The remembrance of this in- 
duced me to employ tepid water only. It is well known, that in ex- 
tensive uterine hemorrhage, cold water, and water variously medicated, 
may be safely employed. But in most 'of these cases, as already ob- 
served, there is at least no evident., and probably no real disease of the 
lining membrane. 

Case 37. 

This, and the following case, are extracted from Dr. Balbirnie's 
work, page 129 ; and I present them here to convey to the reader an 



-j^g LEUCORRHCEA. 

accurate idea of the way in which uterine injections are. employed by 
M Tealier, and perhaps in French practice generally : they are de- 
scribed in the work of this physician on Cancer of the Womb. 

Considerable tumefaction, without induration of the neck of the womb-dilatation 
of its- orifice— profuse leucorrhffia— *n/ec/«ms into the cavity of the womb— cure. 

Madame R- ■, acred thirty years, having had two children, of which the 

vounaesHs four years old, lively and irritable, experienced since a year that she had 
efGnvI^ernativecouniry^olivein Paris, all the symptoms of otenne ea- 
ta rh dull pain in the hypogastrium, in the loins, and in the groins, where she ex- 
ierienced diCreeable diggings when she stood for sometime; a weight on the 
le S which rendered long walks painful, and sometimes imposs.ble-acontinu- 
S an uSand mt discharge from the vagina, of a thick, yeUowish-brown mucus or of 
a alairv matter, like the white of egg, on which were remarked sometimes spots of 
DlobT Pafofai and habitual constipation-loss of flesh-febrile pulse ; the menses 
havincr experienced no derangement. To the touch the neck appeared soft and vo- 
luminous ; and the uterine orifice, much dilated, admitted easily the point of the in- 
dex fin ff er ; all the surface of the os tincee was covered with a thick mucus, which, 
when wiped away, presented a grayish-white colour, contrasting with the red tint of 
the uterine orifice; slight lineary excoriations were observed in the direction ot the 
cavity. On pressure being exercised with the speculum on the body of the womb, a 
considerable quantity of thick mucosities issued from its orifice-pressure with the 
finder on the speculum was painful— the neck was an inch above the perineum. 

Bleedino- from the arm, to the extent of eight ounces, was practised ; and during 
eiaht days'? infections of the decoction of the mallow-root, and poppy-heads, baths a 
mfld regimen and rest, were prescribed. When the pains of the womb were calmed, 
these emollients were replaced by a decoction of a handful of soot in a pint of water, 
with which, each morning, three or four injections were made into the uterine ca- 
vity, by means of a gum-elastic catheter, introduced by one of its ends into the on- 
fice These iniections were performed with facility, and without occasioning pain. 
After having withdrawn the catheter, a pledget of cbarpie, imbibed in the same de- 
coction, was left upon the neck until next day. m 

This treatment was continued during fifteen days, after which they were then 
stopped, in order to ascertain the state of the discharge: it had almost entirely ceased. 
Iniections, nevertheless, were continued every two days during a month. 1 he pa- 
tient then no longer experienced any of the symptoms mentioned, and all treatment 

was suspended. The health of Madame R has not been deranged anew for a 

year succeeding to this treatment. She experiences some leucorrhcea from time to 
time, to which she has been subject from her infancy, and which does not constitute 
in her a diseased state. 



Case 38. 

Soft engorgement of the neck of the womb, bleeding on the slightest pressure- 
habitual leucorrhcea— orifice of the neck largely opened— superficial erosion on 
the posterior lip. Infecundity, the consequence of this morbid state, removed by its 
cure. 

Madame L , aged thirty, of good constitution, and having had only one child, 

ten years ago, was tormented with an habitual leucorrhsea, with a feeling of weight 
at the womb, and some occasional darting pains, which seem to pierce it. Eighteen 
months ago, eight days after the cessation of the menses, there commenced an oozing 
of blood by the vagina, which was very inconvenient to the patient. The discharge 
had continued several months, when medical aid was had recourse to, in the month 

of August, 1834. -■■•**'• 

This lady had been for some time the prey of sadness, from certain painful circum- 
stances, and under the influence of which her indisposition had made sensible pro- 



LEUCORRHCEA. 147 

gress. On examination, the belly was found voluminous, and painful on pressure. 
The pain was especially felt behind the pubis, in the groins and loins; it was dull 
and deep ; at times it had the lancinating character ; the uterus was enlarged sensi- 
bly beyond the vaginal insertion, and descended to within two inches of the os exter- 
num; the neck to the touch was soft and spongy. Seen by the speculum and com- 
pressed by the instruinent, it allowed to exude from all its surface a great number of 
drops of blood ; the edges of its orifice were tumefied, and of a lively red ; on the 
posterior lip there existed a small ulceration, somewhat deep. A yellowish-white 
discharge, proceeding from the uterine cavity, impregnated all these parts, and con- 
tributed to keep up the soft flaccid state of the tissues that was present. 

The patient being removed from the menstrual period, and presenting all the ap- 
pearances of a strong constitution, blood was immediately drawn from the arm to the 
extent of twelve ounces. This bleeding, renewed three days after, stopped the dis- 
charge of blood ; but the leucorrhoeal flux continued in great abundance. Injections 
with soot water were carried, as in the last case, into the uterine cavity ; they were 
continued during three weeks, at the end of which time the leucorrhoeal discharge 
had almost entirely ceased : the womb was returned to its normal state. During 
these three weeks there had not appeared a single drop of blood. The menses flowed 
then regularly; and after their cessation, the os tinc-se was found firm, and permitting 
no more the exhalation of blood ; its orifice was sensibly contracted, and the leucor- 
rhoeal discharge almost gone. 

M. Tealier has informed us that this lady, who had been barren from this cause 
for nearly ten years, immediately afterwards became pregnant. 



Case 39. 

LEUCORRHCEA, DIAGNOSIS DIFFICULT FROM GONORRHOEA. 
OCCURRING IN THE PRACTICE OF MR. TRACY OF CORK STREET. 

May, 1840. Mrs. , set. twenty-three, has been married three years, and 

since the birth of her first child, now eighteen months ago, her health has always been 
delicate, and six months since leucorrhoea appeared. She visited Cheltenham in 
February, 1840, and after an absence of some weeks, during which her health was 
greatly improved, she returned home. The discharge was at this time watery and 
thin, although diminished in quantity. Intercourse was resumed, and, as its conse- 
quence, the husband had all the symptoms of gonorrhoea. In this case the reputation 
of both parties was undoubted ; but still the secretion from the male urethra continued 
for ten weeks, notwithstanding persevering and active treatment. Eventually he was 
cured by steel and a mixture of copaiba mucilage and liq. potassae, with the oxymu- 
riate injection. 



CHAPTER VIII. 

OF THE DISORDERS ATTENDANT ON THE DECLINE OF MEN- 
STRUATION. 

It is impossible, within a reasonable space, to give a correct definition 
of these important affections ; although it is by no means difficult to 
furnish in detail an accurate and condensed account of them. _ I shall, 
therefore, after a few preliminary observations, describe them in some- 
thing like the order of their frequency, beginning with the more com- 
mon, and concluding the summary with the more dangerous deviations. 
It has become too general an opinion, that the decline of this function 
must be attended by illness : but this is surely an error ; for there are 
healthy women, who pass over this time without any inconvenience, 
and many whose indisposition is both transient and slight. That this 
does not more constantly happen, arises from the fact, that nature and 
health are often sacrificed to fashion and luxury. I have already ex- 
plained (at page 29), in reference to the physical Education of female 
youth, how injuriously the national practices affect the establishment of 
the function. The almost entire neglect of out-of-door exercises and 
sports, the substitution of prolonged in-door studies, by which both 
mind and body are prematurely exhausted ; a farinaceous and vegeta- 
ble, instead of an easily digested and nutritious animal diet ; clothing 
inappropriate to our changeable climate, and many other circumstances 
too numerous to be recounted, are productive of results in early life 
conspicuously inauspicious and hurtful. Only let this enumeration be 
completed by the subsequent histories of marriage and childbearing, 
and we shall be convinced, that the ills attendant on catamenial de- 
cline, are attributable,, not to necessity, but mainly to habits, unwisely 
begun, and still more unwisely continued. 

Females themselves anticipate this period as extremely eventful, de- 
nominating it " the critical or dodging time," — "the turn of life," &c. 
Nor can it be denied, that they often have sufficient reason for their 
anxiety. With the extinction of this extraordinary secretion, the re- 
productive faculty dies — an event of itself of sufficient magnitude in 
the life of a woman, to give to this epoch an emphatic interest. The 
consequences may be injurious at any time of life, where even a 
slight evacuation is suddenly stopped ; for although it was originally 
excessive and morbid, such a process eventually becomes so habitual 
and necessary, that it cannot be safely done away, without either pre- 
paratory antiphlogistic treatment, or the institution of some compen- 
sating drain. I have, in an appended note, for which I am indebted 
to Dr. Stroud, given an extraordinary analogous illustration occurring 



DISORDERS ATTENDANT ON DECLINE, ETC. 149 

in the other sex. There are few practitioners, who could not verify 
the statement from their own observation amongst females.* 

We cannot, therefore, be surprised, especially where luxury and 
dissipation, or penury and disease have already injured the constitu- 
tion, that the cessation of two such prominent functions of the female 
economy, as menstruation and reproduction, shall be sometimes ac- 
companied by serious changes in the nervous, vascular, and digestive 
systems. Let it be remembered, also, that these are the distinctive 
functions of the sex, exerting for many years a marked influence over 
their health, and giving even to their disorders a peculiar character — 
not lost till after their final decline. And yet it must not be supposed, 
that the effect of these great changes is always morbid. Sometimes it is 
quite the reverse ; for there are women who have never been vigorous 
and well during the middle period of their lives, and some who have 
suffered from protracted illness or chronic uterine maladies, who after 
this time acquire what they term, " a settling of the constitution," and 
good health. 

If the affections accompanying catamenial decline be classed ac- 
cording to their frequency, there can probably be little if any doubt, 
that— 

Functional derangements of the brain and nervous system , are the most 
numerous. 

Next in amount are the cases of increased action and congestion of dif- 
ferent organs. 

And, happily, amongst the least common, are lesions of structure 
and malignant disease. 

A train of symptoms, fairly to be denominated nervous or hysteri- 
cal, so often accompanies the change, even when most favourably ac- 
complished, that it excites but little attention, if some single symptom 
or the entire affection is not of unusual severity. Timidity, a dread 
of serious disease, irritability of temper, a disposition to seclusion, im- 
paired appetite and broken sleep, with physical weakness and inquie- 
tude, are common indications. Women are aware that such symp- 
toms may be expected to occur, and they are in consequence alive to 
their approach. Of course the cessation does not always take place 
in the same way. Occasionally, but very rarely, it is sudden. The 
individual having arrived at the usual age, anticipated menstruation 
is prevented by cold, fright, or by some illness. These circumstances, 
in earlier life, would have been followed, on their removal, by a re- 
turn of the discharge ; but it is not so now. Nature seizes this oppor- 

* Case of Frederick P . A young man subject to plethora and to large dis- 
charges of blood from the nose every spring, having for some time laboured under 
mental vexation and anxiety, missed, during last spring (184U) his usual epistaxis. 
He became somnolent, morose, and dejected, and at length, after some bodily exer- 
tion, fell into a sort of fainting fit. Under the direction of Mr. Symes of Tavistock 
Square, he was largely bled, with apparent relief. Having been placed in bed, he 
lingered for some hours, with a sense of weight and oppression about the heart, 
which gradually terminated in death. On inspection of the body, about three pints 
of partially coagulated blood were found in the pericardial sac, having been dis- 
charged from a ruptured aperture in the superior cava, which would admit the finger. 
With this exception, there was no other disease, either in the heart or elsewhere. 



150 DISORDERS ATTENDANT ON 

tunity to put an end to the function altogether, and I have known se- 
veral patients thus dealt with, who never had afterwards one hour's 
inconvenience. But a gradual extinction is much more common. One 
period being missed, there is a return ; a longer time then elapses, and 
there is perhaps an excessive return ; afterwards some months may 
pass away without any appearance, then there is a sparing secretion ; 
and in this way the discharge, sometimes amounting almost to a flood- 
ing, and again being so scanty and so slightly sanguineous as scarcely 
to attract notice, altogether disappears. I have already, at page 111, 
mentioned the different ages at which the cessation takes place ; and 
as to the time occupied, it is nearly impossible to afford any precise 
information. Some females pass over the period in a few months, 
others are irregular for a much longer lime, and I have known in- 
stances where several years have intervened between the beginning 
and completion of the change. Hysteria, of marked intensity, not un- 
frequently exists, and in two patients formerly under my care, a 
stranger, seeing the extent of mental aberration, might, without care- 
ful investigation, have concluded that they were really insane. In 
one of these instances, a physician, attending in my absence, strongly 
urged restraint and removal. Soothing, temporizing treatment, how- 
ever, must be adopted in these cases. Irritability is their prominent 
feature ; and as the cessation is a process of nature, it is important 
that its completion should neither be hastened nor delayed by inap- 
propriate management. 

The examples are not rare, where increased action and congestion 
occur as the result of catamenial decline. We do not expect to find de- 
licate women thus suffering, but those who have been plethoric and 
healthy ; who have indulged in good diet and wine, or malt liquor, are 
exceedingly prone to such affections. Nor must it be forgotten that 
the tendency often continues for months, and sometimes for years after 
the entire disappearance of the secretion. Every one at all observant 
of female diseases, must know that women who have been healthy 
prior to this change, often become corpulent after its completion, and 
are more than usually liable to attacks of apoplexy, paralysis, pulmo- 
nary obstruction, and cough. Thus affording an illustration of the 
remark, the correctness of which cannot be doubted, that while certain 
morbid conditions of the cerebrum produce emaciation, there is another 
series, amongst which the influences in question must be placed, which 
induce repletion and obesity. Headache, then, sensations of fulness 
about the cerebrum, throbbings of the carotids, and visible distention 
of the superficial veins of the temples and neck, ought always to excite 
watchfulness if not apprehension. Cases of partial apoplexy and 
paralysis do occur as the result of neglected amenorrhcea in earlier 
life ; and several times I have been struck with the relief afforded to 
affections of the brain, at this period, by an excessive return of the ca- 
tamenial discharge. Affections of the skin, too, very difficult of cure, 
and sometimes almost permanent, are by no means rare. Evanescent 
eruptions about the face and upper part of the body are common. 
But there is scarcely any organ or part of the body, and the statement 
is particularly true of the uterine system, which may not suffer from 



DECLINE OF MENSTRUATION. 151 

acute or chronic inflammation as the direct or remote consequence of 
this great change. Hepatic derangement, and even disorganization, 
have "been frequently attributed to this cause. I cannot, from my own 
observation, confirm the latter part of this statement, although I have 
known the liver, in common with the other chylopoietic viscera, seri- 
ously disordered. 

A very few remarks will suffice on the treatment of these various 
sympathetic affections ; and first, I must be allowed to state, that no 
more serious mistake can be committed, than to attribute any of them, 
without the most accurate inquiry, to debility rather than to repletion. 
Let it be remembered that an accustomed evacuation is about to cease, 
or has finally disappeared ; that the patients have been previously 
healthy, and that the probability therefore is, that the weakness is appa- 
rent not real. If, for instance, because there is languor and inactivity, 
a slow pulse, torpid bowels, and depression of mind, stimulants and 
generous diet are allowed, some important organ will become congested 
— the brain or the lungs — and either suddenly fatal or structural dis- 
ease may occur. I know not how often, but certainly very frequently, 
such errors happen ; and it is, therefore, the more necessary to urge 
especial caution. 

There are instances where too large bleedings have been practised, 
and where the antiphlogistic treatment has been too long pursued. In 
such, and in others, where the active symptoms have been subdued, or 
where from the commencement the disease has been of mixed charac- 
ter, modified measures must be adopted. Further loss of blood and the 
continued exhibition of calhartics will induce anaemia and extreme 
irritability, while a sudden and injudicious alteration of the treatment 
may irretrievably injure some weakened organ or part. Hence, it will 
be apparent that a middle and cautious course must be chosen. I have 
now under my care a lady who has ceased to menstruate for three or 
four years, and who, by the adoption of a spare and vegetable diet, and 
the almost daily use of purgatives throughout the whole time, has be- 
come gradually so exhausted, irritable and neuralgic, that her life is a 
burden. Many months of watchful treatment will be required ere she 
can return again to animal food, on which the restoration of her health 
really depends. More need not be said on these important points. 
Where symptoms of plethora continue — and there are cases where on 
even the poorest diets patients will fatten — purgatives or mild ape- 
rients, occasional small general or local bleedings, exercise, and absti- 
nence from wine, spirits, and malt liquor, must be strictly enjoined. 
On setons and issues great stress was formerly laid, but they are not 
often necessary. Where patients cannot be induced to live appro- 
priately, but will gratify the appetite, at whatever risk, or where the 
brain is evidently the seat of frequent congestion, and serious symptoms 
are constantly present, such remedies are most desirable. Other mea- 
sures of a derivative kind will naturally suggest themselves, as mustard 
hip-baths, and pediluvia, frictions, with stimulating embrocations, and 
the flesh-brush, the continuance of sexual intercourse, and the encou- 
ragement, by any gentle means, of the catamenial flow. 

At page 110, in the section on congestive menorrhagia, the proba- 



152 DISORDERS ATTENDANT ON DECLINE, ETC. 

bility of pregnancy is mentioned. Nor must it be forgotten that con- 
ception does occasionally occur when the process of catamenial cessa- 
tion seems to be nearly complete. The practitioner will not, therefore, 
suppose, if the symptoms of gestation arise, that they must of necessity 
be fallacious. I grant that spurious or mistaken pregnancy is more 
likely ; and many men have exoosed themselves to ridicule by erro- 
neous opinions on this difficult matter. More than this I need not say 
here, as in the " diagnosis of pregnancy from disease" the distinguish- 
ing marks will be fully discussed. 

Lesions of structure and malignant disease.— There is an almost uni- 
versal impression that organic maladies, especially of the breast and 
uterus, are more likely to take place at this than at any other time. I 
doubt whether catamenial decline, as it is a natural process, has any- 
thing to do with their original production ; but I certainly think that 
the development of a latent tendency to disorganization may accrue 
from the derangement, especially where the uterus becomes congested, 
either as a consequence of a superfluity of blood for which there is no 
adequate outlet, or as the result of a neglect of .its proper local abstrac- 
tion. Under such conditions, I can easily understand that tubercular 
or cancerous deposit, either in the uterine or mammary structures, shall 
receive a stimulus of growth, which may, unchecked, lead to rapid de- 
velopment 

It is scarcely requisite to urge a frequent inquiry as to the state of 
these organs ; the breast may easily, if any suspicion exist, be examined ; 
and although there may be obstacles in the way of vaginal investiga- 
tions,' they will readily yield if the necessity to the patient's safety be 
urged as their justification. 



CHAPTER IX. 

FORMULAE OF REMEDIES. 

The following prescriptions are selected from many which are ge- 
nerally used, and which I have been long accustomed to employ in 
the diseases of menstruation, characterized by profusion or excess, and 
in leucorrhoea. 

[For the aperients and purgatives, reference must be made to 
page 93.] 

STOMACHICS AND TONICS, 

I shall only add two additional formulae : — 

Form 46. — Mistura Tonica cum Acido* 

Sir James Clarke. 

R. Acid. Sulph. dil. 3iv. 
Syr. Aurant. ^iss. 
Aquae Cinnamomi £j. M. ft. Mist. 

Take one teaspoonful three times a-day in a wine-glassful of water. If it 
be advisable, a pill containing one or two grains either of the sulphate of iron 
or quinine, with or without a narcotic, may be given with each dose. 

Form 47.— Mist. Ferri Tartratis* 

B. Ferri Tartratis Ammoniat. gj. 
Tinct. Aurant. %]. 
Tinct. Card. C. giv. 
Aquae destillatae ^vjss. M. ft. Mist. 

Take one tea, dessert, or tablespoonful three or four times daily. 

SALINES WITH PURGATIVES. 

Form 48. — Mist. Salina cum Acido. 

R. Infus. Rosae C. ^viij. 

Magnes. Sulph. 5iv. vel 5 vu 'j« 
Pulv. Potassae Nitrate ►)]. vel 9ij, 
Acid. Sulph. dil. Jss. vel 3j. 
Tinct. Digitalis 3iss. M. ft. Mistura. 
Two tablespoonfuls three times daily. If it be necessary to take the fol- 
lowing pill frequently, the meilorrhagic loss being excessive, it should be 



154 FORMULA OF REMEDIES. 

swallowed half an hour or an hour before the mixture. By this arrangement 
a considerable quantity of the acetate of lead may be exhibited, without the 
diminution of its beneficial, and free from the risk of its injurious properties. 

Form 49. 

R. Plumb. Acetatis gr. j. ad ij. vel iij. 

Micse Panis vel Confect. Rosae Gallicse qs. Ft. pilula. 



ASTRINGENTS. 

Form 50. — Mistura Secalis Cornuti. 

R. Tinct. Secalis Cornut. 3iij. 
Pulv. Potass. Nitrat. Jj. 
Aquae Menth. Pip. ^vss. M. ft. Mist. 
Take one tablespoonful, one and a half, or two tablespoonfuls every two 
or three hours ; the dose being repeated more or less frequently, according to 
the urgency of the case. 

Form 51. 

Dr. Dewees. 

R. Spir. iEther. Sulph. C. 
Tinct. Opii. aa gtt. xxx. 
Aquae Menth. Pip. 5vij. M. ft. Haust. 
One draught to be taken every hour (in cases of alarming menorrhagia or 
profuse menstruation), with the following pill : — 

R. Pulv. Opii. gr. 1. 
Plumb. Acet. gr. ij. 
Cons. Rosae Gall. qs. Ft. pilula. 

Form 52. 

Dr. Dewees. 

R. Infus. Rosae C. §j. 
Elixir vitrioli Klxx. 
Magnes. Sulph. 3iss. M. ft. Haust. 
One draught to be taken every six hours with or without the lead. 

Form 53.- — Mist. Terebinth. Comp. 

R. Spir. Terebinth. C. ^Ixv., xx., ad xl. 
Mucil. Acaciae 3vij. 
Spir. Lavand. C. 3j. M. ft. Haust. 

One draught every four, six, or eight hours. I have given this with 
marked benefit in menorrhagia, where the loss is not excessive, but protracted, 
occurring in connexion with leucorrhoea ; a few drops of tincture of opium 
may be added. 



FORMULA OF REMEDIES. 155 



Form 54. — Mist. Copaibse Comp. 



R. Balsam. Copaibas ^j. 
Mucil. Acacias. 3ij. 
Sp. Lavand. C. ^ij. 
Mist. Camph. 3v. M. ft. Mist. 

One or two tablespoonfuls to be taken three or four times daily. The effi- 
cacy of this mixture is increased, if it can be borne on the stomach, by the 
addition of one or two drachms of the powder of cubebs. The tinctures of 
cubebs, cantharides, and capsicum, are frequently beneficial in protracted or 
dropping menorrhagia ; and in chronic and inveterate leucorrhcea, fifteen or 
twenty drops of each may be administered three or four times daily in water, 
or in an ounce of mucilage. I have lately used the Extractum Hasmatoxyli, 
in doses of fifteen or twenty grains, three times a-day ; continued for several 
weeks ; it must be suspended in water or mucilage, for if given in pills they 
become so hard that they will pass through the body unchanged, and without 
effect. 

It is scarcely necessary to give the more common astringent lotions 
and injections, although I do not wish it to be inferred from the omis- 
sion, that I think lightly of their efficacy. The compound alum wash, 
if well used, is one of the most valuable remedies of the kind we 
possess ; but there are tedious examples of leucorrhoea, in which more 
powerfully astringent and stimulant means must be employed. 

Form 55. — Injectio Jlstringem. 

R. Decoct. Secalis Comut. ^xiv. 
Argenti Nitrat. gr. xx. 

Tinct. Catechu fij. M. ft. Injectio vaginalis. 
Four ounces to be used three times a-day. The decoction of the secale is 
to be prepared by boiling one ounce of the bruised rye in a pint and a half of 
water, down to a pint. 

Form 56. — Injectio Jlstringens. 

Dr. Copland. 

B. Inf. Q,uercus ^iv. Pulv. Gallarum gr. xxx. 
Tinct. Catechu 3ij. Ft. Injectio vaginalis. 
To be used once, twice, or three times daily. 



i / 



Form 57. — Enema Jlstringens, 

Dr. Mackintosh. 

R. Plumb. Acetat. gr. xv., xx. 
Aquas puras Jiv. Ft. Enema. 

To be used by the rectum once or twice daily. 



1 



156 FORMULJE OF REMEDIES. 



Form 59. — Injectio Argenti Nitrat. 

H. Argenti Nitrat. gr. xv. ad gj. 

Aquae Rosas ^xvj. M. ft. Injectio vaginalis. 

Three or four ounces to be used three or four times daily. In cases where 
an unhealthy condition of the vagina or cervix has been ascertained to exist 
by the speculum, or where, independently of such state, the discharge is in- 
veterate, a much stronger solution is sometimes required, and with this, by the 
aid of the tube, the diseased parts may be directly touched, or washed once 
or twice daily, a camel-hair pencil being used for the purpose. In a protracted 
example of leucorrhcea lately under my care, the nitrate of silver was thus 
used, and with curative effect. Of all the mineral astringents it is the best. 
Dr. Jewel remarks, ** that by some it is thought, that the checking of a va- 
ginal discharge must be prejudicial. This opinion," he says, "is at variance 
with my own"experience ; but I would employ the nitrate of silver, not merely 
with a view of arresting the discharge, but to produce a perfectly new action, 
or new excitement, in the part from which the secretion has its origin. The 
mode I have adopted in the application of this agent, has been either to con- 
ceal it in a silver tube, as it is employed in cases of stricture (except that the 
tube should be adapted to the size of the " argenti nitias"), or in the form of 
a solution, in the proportion, generally, of three grains to the ounce of distilled 
water, the strength being gradually increased. A piece of soft lint may be 
moistened with the solution, and introduced into the vagina, for a short period, 
several times in the day, or a bit of sponge, firmly and neatly tied to the end 
of a slip of whalebone," and well saturated with the solution, may be passed 
into the vagina, up to the os and cervix uteri. This can easily be effected by 
the patienf herself. It is necessary that the application should be frequently 
repeated, or no permanent benefit can be expected. Should it become requi- 
site to employ a strong solution, and to apply it to a certain part, or ulcerated 
surface, it can be accomplished with a great degree of nicety, by means of a 
camel's-hair brush introduced through the speculum or dilator." 



Form 59. — Injectio Ferri Sulphat. 

R. Feiri Sulphatis gj. ^ij. vel 3J. 

Aquae destillatae 3xvj. M. ft. Injectio vaginalis. 
Four ounces to be employed three or four times daily. I have of late dis- 
continued the use of syringes, for vaginal injections ; india-rubber bottles, fitted 
with ivory tubes, are far better : there is less difficulty in their employment, and 
they are not so apt to get out of repair.* 

Form 60. — Injectio Sodse Carbonat. 
Dr. R. D. Thomson. 

£. Sodae Carbonat. t)j. 9ij. vel 3j. 

Aquae Purae 5xvj- M. ft. Injectio vaginalis. 

Four ounces three or four times daily. 

* Patients should be told that the last two forms (58, 59) will spoil any linen 
which they may happen to soil, imprinting an indelible stain. 



FORMULA OF REMEDIES. 157 

Dr. Thomson is said by Mr. Jones, in his "Practical Observations 
on the Diseases of Women," to have ascertained, by repeated expe- 
riments, that inflammation of mucous membranes always engenders 
a free acid on their surface, which acts there as an irritant increasing 
inflammation. To neutralize this, he makes use of the alkali. Mr. 
Jones confirms this opinion by stating, that whenever litmus paper has 
demonstrated the presence of a free acid, almost immediate relief has 
been obtained by the use of the alkali. So far as my exhibition of this 
remedy goes, it supports these views; certainly in several examples of 
acrimonious leucorrhoea, it has quickly relieved, and several times cured 
the malady. 

Form 61. — Tnjectio Succ. Limon. 

R. Succ. Limon. recent, gj. vel ^ij. 

Aquae Puree gxv. vel gxvj. M. ft. Injectio vaginalis. 

To be used either warm or cold, as directed above. 

Acetic acid in the proportion of half an ounce to a pint of water; nitric, or 
muriatic acid, ten, twenty, or thirty minims to a pint of water, may be advan- 
tageously used in protracted leucorrhoeal discharges. Their effects will be 
either sedative or stimulant, in proportion to their strength. In a diluted form, 
they will often soothe ; whilst in greater intensity, they will not only stimu- 
late, but induce excessive irritation. The sulphate of copper 9j. vel 5J. to a 
pint of water, or the decoct, secali, is often beneficial ; nor must the injection 
of the black wash or the oxymuriate lotion, be forgotten. Electricity, and a 
blister to the sacrum, are valuable remedies ; and I am anxious to give a place 
to the following excellent combination of Sir Charles Clarke : — 

B. Infus. Cascarillae %]. 
Aquae Pimentae ,^ss. 
Tinct. Sabinae C. 3j. ^iss. vel spj. 
Syr. Zingib gj. Ft. Haust. 

To be taken three times daily. 
11 



CHAPTER X. 

OF HYSTERIA. 

Definition. — An assemblage of symptoms, generally in a paroxysmal 
form, simulating many and opposite diseases. Usually produced by func- 
tional derangement, the consequence of irritability of the general, but espe- 
cially of the uterine nervous system, attended by mental emotion, increased 
secretion of limpid urine, flatulent rumbling of the bowels, a sensation' of 
a ball ascending from the umbilicus towards the oesophagus, a feeling of 
suffocation and more or less convulsive spasm. It is often protracted, 
sometimes incurable, but never perhaps immediately dangerous to life, and 
it leaves, if any, very slight traces of its existence after death. 

It is difficult, within reasonable limits, to present a correct and com- 
prehensive exposition of this extraordinary disease. Still in a work 
devoted to maladies peculiar to women, hysteria ought to find a place 
— although I am confident I have seen marked instances of the affec- 
tion in susceptible, but otherwise healthy males; it cannot therefore 
be regarded as exclusively belonging to the sex. Dr. Conolly, whose 
treatise on the disease is invaluable, concurs in this opinion, and it 
is also supported by many writers of respectability: Dr. Copland, in 
his learned and most extraordinary dictionary of practical medicine, 
says, "that he has never met with a case in which the complaint was 
unequivocally developed in men, but he has seen several nervous 
affections in males of a susceptible irritable temperament, weakened 
by disease or by over-exertion, which have assumed some of the cha- 
racters of hysteria, particularly in its irregular or undeveloped state. ' : 
Several examples of new forms of hysteria have lately been brought 
to light, and the unfolding of the nervous system, must extend our 
knowledge of the space within which it may exist. Thus a correct 
idea of the nature of hysteria, is more important than an enumeration 
of its varieties: for although it is nearly impossible, or at least very 
difficult exactly to define what is meant by an hysteric affection, we 
may at least understand, that in every instance it comprises a series 
more or less regular and complete of symptoms, induced not by struc- 
tural lesion but by morbid action — hence it will be inferred, that its 
phenomena must be exceedingly various, and when it is remembered, 
that the uterus is supplied with nervous influence by the ganglionic 
system, we cannot wonder at its diversified symptoms. Mr. Aberne- 
thy said that irritability was "little more than debility excited," and if 
this condition were constantly recognised — female diseases, depend- 
ent on irritation or of so mixed a character that neither inflammation 
nor debility predominates, would be more wisely treated, and instead of 



HYSTERIA. 159 

depletive and drastic purging, measures of an alterative and soothing 
kind would be curatively employed. As society advances in refine- 
ment and luxury, such distinctions become more valuable. And in 
crowded cities, and manufacturing and thickly-peopled towns, they 
are peculiarly important. Nearly all the viscera of the body may 
surfer from the hysteria ; but especially the head, chest, and abdomen, 
and the uterine system are most frequently implicated. The description 
of an attack of hysteria, will give the best idea of its varied character, 
and afterwards, its more unusual complications, protracted duration 
and effects, may be explained. The paroxysm is easily excited, par- 
ticularly where the disease is established. Inordinate physical effort 
and sudden mental emotion almost certainly induce it. A distinct 
hysteric fit generally begins, with painful sensations about the umbili- 
cus ; these, gradually and with rumbling noise, following the convolu- 
tions of the intestines, ascend through the stomach towards the throat, 
assuming at this part of their course a defined form and character, 
which the patient likens to a ball, and which, as it continues to mount 
upwards towards the (esophagus, appears to fill the whole calibre of 
the canal, and produces sensations of choking or even of suffocation. 
It seems evident, however produced, whether by action transferred 
from the uterus or more directly through the nervous system, that 
there is at this period decided spasm of the passage. The paroxysm 
having proceeded thus far — the fit is at its height, and a burst of cry- 
ing or laughter, of longer or shorter duration, and followed by a period of 
exhaustion, and by a large flow of limpid urine, terminates the attack, 
and the patient sometimes quickly and occasionally very gradually 
regains her accustomed composure. There are many modifications 
of the hysteric seizure : often it assumes a more formidable aspect — 
the movements of the different parts of the body are convulsive and 
epileptic, the sobbing and laughing occur alternately, and with extreme 
violence — the heart may be seen to palpitate, the vision and hearing 
are impaired ; the power of articulation is suspended, the patient is 
unable to move, and there seems to be profound syncope, and entire 
unconsciousness. This latter condition is occasionally apparent only, 
the patient after her recovery telling her medical attendants the sub- 
stance of their conversation, during the attack ; hence caution is re- 
quisite in the expression of any alarming opinion about the duration or 
danger of the affection. Several of the sphincters may be completely 
contracted, and the anus has been known to resist the introduction of 
a common-sized enema pipe. The events now related form a part of 
most hysteric paroxysms, which in some women occur so often, and 
from such trivial causes, as scarcely to excite attention : they but 
slightly impair the general health, and are often so much under the 
control of the will, that they may be postponed or induced nearly at 
the pleasure of the individual. It is not therefore a matter of surprise, 
that sarcasm and irony should so often have been the means adopted 
for their cure. But it must be stated, that it is not always easy to 
distinguish hysteria from more serious diseases, and there are few prac- 
titioners, who have not occasionally been perplexed to determine 
whether certain symptoms were the accompaniment of the functional, 



160 HYSTERIA. 

or of a serious affection. Sometimes the attack has so far exceeded 
the usual duration, as to excite real apprehension for the recovery of 
the sufferer, and to have made it difficult to determine whether the ex- 
haustion and syncope, the feeble pulse and powerless heart, were not 
the consequences of a concealed organic malady, rather than the effect 
of a comparatively harmless functional disease. Certain it is, that in 
some rare cases, after severe and repeated attacks, marked collapse 
occurs ; such instances I have twice seen. The respiration was 
scarcely appreciable, the heart could hardly be felt to beat, the pulse 
was nearly gone at the wrist, and the surface generally and especially 
the extremities were so clammy and lifeless, as to remind me very 
strongly of cases of fatal flooding. Dr. Copland notices these forms, 
and says, " that some of the instances of supposed death, in which 
persons have narrowly escaped being buried alive, were of this kind ; 
he further adds, that he has seen some examples of this hysterical syn- 
cope, so severe as to occasion alarm, and M. Villermay considers that 
death may supervene upon it." The distinguished anatomist Vesalius 
mistook such a case for real death, and having commenced the dis- 
section of the body, the first incision roused the dormant life of the 
woman, and convinced the operator of his error. In the " Journal de 
Savans" for 1745, the remarkable case of the wife of Colonel Russell 
is related — who remained in a state of complete hysterical syncope 
for many days, and who would in all probability have been buried 
alive, had it not been for the devoted affection of her husband, who 
would not allow himself to be taken from her apartment, and thus se- 
parated from her supposed dead body. 

If, as I believe, the disease generally has its origin in nervous irri- 
tation — that portion of the organic nervous system which supplies the 
organs of reproduction, being most frequently implicated, it is not 
difficult to understand, that the various diseases of menstruation, and 
the periods of the commencement and decline of this important function, 
should most frequently be associated with its attacks — hence it may 
truly be inferred that the disappearance of the hysteria, will often be 
contemporaneous with the removal of these affections. This is true, 
but nevertheless it is equally so, that hysteria attacks women perfectly 
free from uterine derangement, some of the worst and most protracted 
examples having occurred after the cessation of menstruation. Thus 
hysteria varies in its method of approach, its character, its severity 
and duration. In some individuals there are scarcely any premonitory 
symptoms — the exciting causes suddenly producing the paroxysm ; in 
the majority, headache, spasmodic twitching about the larynx, and a dis- 
position to hiccup, and irritability of temper, precede the seizure for 
some hours, or perhaps for one or two days. In these latter examples, 
the hysteria might often be prevented. Not unfrequently, the disease 
is stationary as to severity, and after months or perhaps years' con- 
tinuance the paroxysms and the health remain much as they were. 
This, however, is not always so; illness, domestic trials, or a severe 
disappointment in love, may convert a slight and regular hysteria into 
a malady resembling in many respects the convulsions of epilepsy or 
apoplexy. Still the previous history and a knowledge that the hysteric 



HYSTERIA. 161 

diathesis really exists will guide the practitioner. In some of these com- 
plicated forms, there will be severe spasmodic constriction about the 
throat amounting almost to suffocation or at least to the strongest im- 
pression that it w r iil occur, and lasting for many hours ; in others, con- 
vulsive movements of the head and body, and of the arms and hands, 
are the most prominent symptoms. Occasionally in the hysteria of 
plethoric women, the respiration is so slow and laborious, the trunk of 
the body so stiff and motionless, the veins of the neck so much distend- 
ed and the face so flushed or livid and swollen, as to induce a fear that 
apoplexy may supervene. The violent movement and efforts of the pa- 
tient, and the increased action of the heart and pulse, aided by a know- 
ledge of previous disease, will guide both the diagnosis and the prog- 
nosis. There are examples of hysteria, w T here the symptoms scarcely 
amount to a distinct seizure ; lasting for two or three days, or even for 
a longer time. These occur in individuals of highly susceptible tem- 
perament, who have long suffered from the disease, and who are, or 
think they are, the subjects of especial troubles ; occasionally, the pecu- 
liarities of such patients are so marked and permanent, as to give rise 
to a belief, that insanity will take place if it does not already exist. 
These forms I have seen and their treatment has been difficult; several 
of them arose from disappointed affection and delayed marriage, — and 
were complicated with excitement of the sexual system, and local irri- 
tation of the uterus and its appendages. Occasionally also, distressing 
and intense headache, affecting only a small part of the cranium — a 
peculiar loss of voice and croupy spasmodic cough — induced by slight 
causes, such as atmospheric changes, an east wind — or unfounded 
apprehension, bring on an attack and constitute its diagnostic charac- 
ter. It were easy to amplify these complications, but enough probably 
has been done to furnish an instructive history of the disease. 

Sir Benjamin Brodie has most beneficially directed professional at- 
tention to the affections of the joints in hysterical females, thus ex- 
tending the domain of this proteiform malady. Nor must I forget to 
allude to those painful and irritable states of the breast so common in 
hysterical females and almost uniformly associated with amenorrhoea. 
I have seen the gland generally enlarged and indurated, and in two 
cases the hardness was so distinct and real as to excite apprehension 
that it might have been malignant — in both the hysteria had produced 
the irritation — in one it had assumed the form of irritable tumour, while 
in the other irritation was more generally diffused. In two similar cases 
there was marked pain along the dorsal spine ; and at the origin of 
the nerves, there was so much tenderness, that gentle pressure could 
scarcely be borne : spasmodic twitchings were the consequence of the 
examination, and the pain extended down the arm, even to the wrist. 
Generally, the cure of the amenorrhoea or the removal of the congestion 
of the blood-vessels of the spine, by cupping or leeching, is contempo- 
raneous with the disappearance of the mammary affection. 

It were easy to increase the number of these more anomalous affec- 
tions, and thus to afford proof of the truth of Sydenham's observation, 
that hysterical disorders really constitute more than one-half of all 
chronic distempers. He correctly remarks, " that hysteria is not more 



162 HYSTERIA. 

remarkable for its frequency, than the numerous forms under which it 
appears, resembling part of all the distempers wherewith mankind 
are afflicted: for in whatever part of the body it be seated, it imme- 
diately produces such symptoms as are peculiar thereto ; so that un- 
less a physician be a person of judgment and penetration, he will be 
mistaken, and suppose such symptoms to arise from some essential 
disease of this or that particular part, and not from the hysteric pas- 
sion." 

A brief enumeration of the various affections dependent on or asso- 
ciated with hysteria, will give the best idea of its proteiform character. 
In many instances, the hysterical phenomena are accompanied by pul- 
sations of the aorta, so violent and circumscribed, and recurring so fre- 
quently, and on such slight excitement, as to induce a fear in the pa- 
tient's mind, that there must be organic disease. I knew one lady 
harassed by these beatings of the artery, for several years — the first 
attack having supervened after domestic trial and abortion. The affec- 
tion did not cease till the final disappearance of the catamenia. Enor- 
mous and almost incredible development of air in the intestines, is fre- 
quent in hysteria; the accompanying dyspnoea, abdominal constriction, 
and pain are most distressing: and if eructation does not soon occur, 
spasmodic almost convulsive muscular action may take place : palpita- v 
tion, flushing of the face, disturbed circulation, and a complete hys- 
teric fit, often succeed. Constipation, irritability of stomach, and vomit- 
ing — depraved appetite — and as the result of these morbid states, great 
depression of spirits, are common. Perhaps no function is more fre- 
quently disturbed by this extraordinary malady than the respiration ; 
hurried, short, spasmodic breathing is excited by the slightest motion, 
or by the most trivial incident, if at all unexpected. A peculiar sono- 
rous cough, accompanied by croupal breathing and apparently by a 
spasm of the glottis, is frequent amongst the hysterical. A severe and 
protracted case of this kind I saw lately with Mr. Law, of Finsbury- 
square. The paroxysms w T ere easily induced : hurry and alarm, an east 
wind, fatigue, or an error in diet, were almost sure to cause them. The 
affection was however so well characterized, that the patient herself 
called it her " hysteric asthma." Depletory and antiphlogistic treat- 
ment is sometimes erroneously and injuriously adopted. Apparent 
obstruction or even closure of the gullet, the rectum or vagina, are 
symptoms of hysteria. Dysuria also, and indications of stone in the 
bladder, with disordered conditions of the urine, are not unfrequent, 
and can only be referred to deranged function of the cerebrum or spi- 
nal marrow. Slight jaundice, as an accidental complication of hys- 
teria, accompanied with spasmodic pain in the region of the liver, I 
have twice seen. In both cases hysteric diathesis had long existed : 
mild aperients, sedatives, and a carefully regulated diet, were cura- 
tively employed. Sudden and violent attacks of general abdominal 
pain, and especially of colic, are met with ; and from their severity 
and duration, often lasting for many hours and occasionally for se- 
veral days, seriously perplex the practitioner. Bleeding and drastic 
purgatives do mischief; but narcotics and mild aperients, the latter 
frequently bringing away copious dejections of dark scybalous fasces, 



HYSTERIA. 163 

afford great relief. Disturbed sleep and occasionally after an attack, 
heavy sleep accompanied with snoring, are common to this class of 
patients. Hysteric hiccup is by no means rare, hysteric dysphagia, 
and spasmodic exclamation have been mentioned and illustrated by 
examples, in Dr. Bright's works. A point of consequence in these 
affections is their tendency to recur at stated intervals ; a forgetful- 
ness of which has sometimes led to their being improperly classed with 
ague. 

Having thus described the symptoms constituting the hysteric par- 
oxysm, I beg to observe, that the hysteric diathesis deserves especial 
attention. A knowledge of its existence, either alone or complicated 
with real illness, often guides, not only the opinion as to the character 
of the malady, but the treatment also. It is difficult exactly to de- 
scribe the nature of a pervading hysteria ; and yet there are few obser- 
vant practitioners who do not ascertain and appreciate its existence. 
Its diagnosis may not admit of easy explanation, but a conviction of 
its presence rests on the mind. In such instances, pain, which would 
lead an ignorant physician to bleed and give mercury, suggests to 
one better informed, the propriety of abstaining from both : if asked 
the grounds of his opinion, he will refer to a certain something perva- 
ding the whole series of symptoms, very different from severe inflam- 
•mation. The pain may be acute ; the pulse quick ; the skin hot ; and 
the entire system highly excited : still it is evident that there is some- 
thing associated with all these indications of a transient and functional 
kind ; an affection indeed of the nervous system, irritability and not 
inflammation. If he acts upon this conviction, and does not bleed and 
purge, but soothes and supports, by narcotics and bland nourishment, 
the truth of his opinion becomes apparent, and the result proves, that 
hysteria is very rarely either an active or dangerous malady. 

Nor is the mind in these patients less susceptible than the body. 
Sydenham correctly and beautifully describes their temper and mental 
state. He says, " that upon the least occasion, they indulge terror, 
anger, jealousy, distrust, and other hateful passions ; and abhor joy and 
hope and cheerfulness, which, if they accidentally arise, as they seldom 
do, quickly fly away, and yet disturb the mind as much as the depress- 
ing passions do, so that they observe no mean in anything, and are 
constant only to inconstancy. They love the same persons extrava- 
gantly at one time, and soon after hate them without a cause ; this 
instant they propose to do one thing, and the next, change their mind, 
and enter upon something contrary to it, but without finding it : so 
unsettled is their mind, that they are never at rest." Of course there 
are degrees in hysteria, and this picture is true only of the more estab- 
lished cases. Still it must not be forgotten how nearly the hysteria of 
some women approaches to insanity. Already, at page 150, under the 
head of catamenial decline, 1 have mentioned a corroborative fact; 
and I have now under my care a lady, whose hysterical headaches 
have been so frequent and intensely severe, as to have induced trains 
of thought so morbid, caprices so singular, and conduct so eccentric, 
that any one unacquainted with her real character, might at these 
times excusably suppose her to be insane. Dr. Conolly says, " that 



154 HYSTERIA. 

cases of this kind approach near to insanity, and, indeed, a mind sub- 
ject to the violent agitations incidental to the hysteric constitution can- 
not be considered as perfectly sane. We would here beg to insert a 
caution, to which the young practitioner cannot pay too much attention. 
We are inclined to think that cases of hysteria, in which the mind 
was principally affected, have occasionally been treated as cases of 
simple mania, and the patient placed in confinement with lunatics. 
Nothing more likely to have the most unfortunate effects upon the pa- 
tient co°uld possibly happen ; and no care can be too great to avoid a 
mistake, which would in all probability render such a case incurable 

and hopeless." 

Hysterical patients entertain the most exaggerated idea of the 
danger of any new pain, or of any real or supposed disease with which 
they may be attacked. A morbid susceptibility pervades their entire 
nervous system, and they are in consequence the prey of many false 
impressions. Often have I been summoned most urgently in the mid- 
dle of the night ; and if I had believed even one-half of the vivid de- 
scriptions given by themselves of their sufferings, nothing short of a 
conviction of extreme danger or of approaching dissolution, could fail 
to have been produced. 

In concluding this section of this most extensive subject, it is espe- 
cially necessary to remark, that hysteria has its limits. And although 
I agree with Sydenham and with Sir Benjamin Brodie, as to the pre- 
valence of the "hysterical constitution," still we must be on our guard; 
lest, misled by apparently fugitive, yet frequently-recurring and hyste- 
rical symptoms, we sooner or later mistake diseases dependent on con- 
gestion, or on changes more decidedly organic, for hysteric, or func- 
tional maladies only. Mr. Goodlad has recently directed us to this 
interesting point, and has illustrated and confirmed the fact, that dis- 
eases long and injuriously believed to be merely hysterical, or in other 
words, dependent on a nervous system differently constituted from the 
majority, are really the product of inflammation, congestion, and ef- 
fusion at the roots of previously irritated nerves : thus involving the 
vascular as well as the nervous portion of the animal economy. Dr. 
Conolly and every intelligent practitioner maintain such opinions : in- 
deed the former expressly remarks, " that any function may, in the 
hysterical constitution, be readily disordered ; as, the respiration, the 
circulation, the digestion of food : any part may be affected with pain and 
the usual symptoms of confirmed disease ; and, at length the parts thus 
affected may really become the seat of inflammation or other disorder, 
and undergo a change of structure. For these ultimate results of hys- 
teric disorder the physician should in all severe cases be prepared.'' 

Mr. Goodlad's remarks are really valuable, but they do not at all 
affect the views of Sir Benjamin Brodie ; for, although the former au- 
thor has recalled professional attention to a class of cases which he 
feared, perhaps unnecessarily, might, through deference to so high an 
authority, be overlooked or mistaken, still, to the distinguished surgeon 
already mentioned, belongs the credit of discovering, and especially 
pointing out a much larger series, dependent on functional derange- 
ment: and to be cured only by the utter avoidance of that depletion, 



HYSTERIA. 165 

drastic purging, blistering, issues, and spare diet, so generally and so 
very injuriously practised in this class of affections, prior to the expo- 
sition of his opinions, and which Mr. Goodlad correctly advocates for 
the far more rare organic diseases he adduces. 

Causes. — There are few, if any, points on which medical writers 
have been more agreed, than in attributing hysterical diseases to irrita- 
tion of the uterus, as their sole primary cause. In this view I cannot 
entirely concur; for although it must be conceded that such a cause is 
more universal than all others, still hysteria has been seen in the male, 
— Trotter, Whytt, Ferriar, and Conolly, having recorded such exam- 
ples; and instances are not wanting of its occurrence before puberty 
(Willis and Conolly), and after catamenial decline. Dr. Bright,_ in- 
deed, has published a decided case of nymphomania after cessation, 
accompanying uterine disease. Such facts are sufficient to prove that 
the uterus has been too exclusively regarded as the " fons et origo" of 
the disease. Any circumstances, and such are very numerous, capa- 
ble of producing an excitement of the nervous system generally, or 
of any particular part of it, may lead to hysteria, — hence intestinal 
irritation frequently, and more rarely plethora, mental anxiety and im- 
pressions, sudden changes of atmosphere, and anaemia are exciting 
causes. 

Dr. Conolly remarks — " Of the predisposing cause we can only say, 
that it is a peculiar and constitutional susceptibility to impressions, with 
an inherent" disposition to institute certain actions affecting particular 
organs and functions, the object of which actions seems to be the relief 
of the nervous, system, sometimes by the equalization of the circula- 
tion. We are not more able to explain the form of these actions, or 
the hysterical paroxysm which supervenes on the cerebral excitement 
springing from the primary irritation, than we are to explain the 
ordinary phenomena of laughing or crying, arising from a similar cere- 
bral excitement, originating in impressions primarily affecting the 
mind." 

Deranged menstruation is one of the especial causes of hysteria. 
Prior to puberty the disease is seldom seen ; afterwards, up to forty- 
five, and sometimes beyond, it is common. It is, probably, most fre- 
quent from eighteen or twenty to about thirty, and from thirty-eight 
or forty to the period of menstrual decline. I have known several in- 
stances where hysteria occurred for the first time, at this latter epoch, 
but not more than a very few after the final disappearance of the ca- 
tamenia. Already, at page 29, many circumstances of mismanage- 
ment in the physical and moral education of female youth, inducing 
chlorosis, are pointed out; and these also favour hysteria. A ner- 
vous, lymphatic or sanguineo-nervous and irritable temperament, a 
congested vascular system, with deficiency of tone and increased sus- 
ceptibility to impression, predispose to the malady. Where plethora 
existed, the disease, in my hands, has been more severe and convul- 
sive, than in females of spare or emaciated habit, where the truly ner- 
vous form generally prevails. Hysteria is more common among the 
higher and luxurious ranks of society than among the peasantry — 
although no class is exempt. Hereditary tendency; a climate, like 



166 HYSTERIA. 

our own prone to vicissitudes; tight lacing or pressing, by which the 
digestive organs are displaced and intestinal irritation produced, may 
also be mentioned; anxiety, celibacy, and early widowhood; sexual 
excitement and disappointment; solitude and vicious sexual indul- 
gences, diseases impairing the strength, frequent and disproportionate 
mental effort, and many other circumstances, may be enumerated as 
causes. 

Pathology. — In every case of hysteria, it may be assumed, that there 
is disorder of the nervous system; although its precise nature and ori- 
gin may not be easily recognisable. Much of what has been already 
advanced bears on the pathology of the affection, and if it be conceded 
as a fact, and few doubt it, that the hysterical naturally possess exces- 
sive susceptibility of the nervous system, some advance will have been 
made towards the exposition of its nature. From the commencement 
of life, even in early infancy, a marked difference in the degree of 
sensibility exists. Some children are, to use a common but forcible 
expression, u all nerve," while others, and adults also, are almost stu- 
pidly insensible to influences of intense power. A physiognomist, or 
phrenologist, would furnish a real or supposed elucidation of these dis- 
tinctions, and it is certainly true, that these peculiar traits of nervous 
character are rarely lost; they grow and expand, so that in mature life 
their existence and indications are as distinct as in earlier years. 

Nor is the nervous organization alone affected: the vascular system 
yields to the same predisposing causes. Thus, in some instances, it 
is difficult to determine the priority of affection. An irritable, vascular 
and a susceptible nervous organization, lead to different immediate re- 
sults from the same causes. Thus worms — a flatulent or acid stomach 
may at one time produce as a primary effect, morbid excitement of the 
heart and great vessels, evidenced by palpitation, quick pulse, and a 
hot skin; in the train of which symptoms, extreme nervousness, or a 
regular hysteric fit of sobbing, crying or choking, shall occur. At ano- 
ther time, the hysteric seizure shall be the primary occurrence, and the 
vascular disturbance, secondary. Precisely the same diversity of con- 
sequences may ensue from a deranged uterus, or from sudden mental 
emotions; or the brain being disturbed by any of these circumstances, 
the spinal marrow and thence the nervous centres become affected ; 
after which, according to Dr. Marshall Hall — the originality and ex- 
tent of whose views are securing to him the praise he so richly deserves 
■ — the irritation will be reflected to the nerves of other parts. Thus, 
the original nervous susceptibility becomes the source of most diversi- 
fied results. In some instances, and I lately attended a case of this 
kind with Mr. Leese, of Baker Street, the nervous centres are the seat 
of intense irritation, occurring with remarkable regularity, and produ- 
cing a most painful affection of the intestinal nerves. In others, the pri- 
mary irritation may be more widely diffused, and the organs of loco- 
motion and feeling may be principally affected; fainting, unconscious- 
ness, and entire but temporary loss of the power of moving, being the 
result. 

Nor must it be forgotten, that derangement of the stomach and 
bowels is not unfrequently the source of the irritation on which de- 



HYSTERIA. 167 

pends the hysteric attack. And this remark is not less true, even in 
protracted examples, where a too constant regard to the immediate 
hysterical symptoms has excluded careful inquiries into the state of 
the alvine secretions ; the restoration of which to a healthy condition, 
has, for a time at least, stopped the hysteric attacks. 

The slight results of hysteria astonish us. It is often, perhaps gene- 
rally, a protracted disease, and its phenomena are so violent that an 
inexperienced practitioner might suppose that it must compromise 
life; and yet in itself, it can scarcely be regarded as fatal. M. Lou- 
ver Villermay (Traite des Maladies Nerveuses, p. 70) has quoted an 
example, where a most violent hysterical fit ensued on the sudden sup- 
pression of the catamenia, in consequence of terror, which lasted for 
forty-eight hours, and nothing having been done for the patient's re- 
lief, she died on the third day, being only fifteen years of age. On 
dissection the stomach was found contracted; the left cavities of the 
heart were empty, as were also the pulmonary veins — whilst the right 
cavities, the pulmonary arteries, and the veins, were gorged with black 
blood, chiefly coagulated. The cerebral veins and the sinuses of the 
dura mater contained much blood ; but there was no appreciable alte- 
ration of the brain or spinal marrow, or their coverings, or in the 
nerves. The uterus does not seem to have been examined : — whether, 
therefore, intense inflammation did not exist in its lining membrane is 
not known ; but the ovaries were very large and firm, and enveloped 
in a partially transparent tunic. In the interior of the ovaries there 
was a large collection of round vesicles, filled with an abundant mu- 
cous fluid, which required for its escape the separate puncture of each 
vesicle. 

M. Villermay adduces the evidence of Diemerbrock, Riolan, Vesa- 
lius, and Morgagni, in confirmation of similar morbid alterations, oc- 
curring in the ovaries as the consequence of severe and protracted 
hysteria. It must not, however, be assumed that such changes are 
constant, for certainly, from the extreme unfrequency of a sudden ter- 
mination of hysteria, it must be difficult to arrive at any positive con- 
clusions. When death does occur, the hysteria will generally have 
become an accompaniment only of the fatal secondary malady ; and 
any changes of the uterus or ovaries, where phthisis, dropsy, or atro- 
phy may have supervened, will be entitled to slight regard, as evi- 
dences of the lesions induced by hysteria. Nor where congestion or 
inflammation of the brain, or apoplexy, have in connexion with this 
disease suddenly terminated life, can much confidence be placed in 
any such changes. 

It is, however, of great practical utility to remember, that where 
the hysteric diathesis really prevails, recoveries sometimes occur from 
states in which all hope has been laid aside. Thus paralysis, and 
difficulty of swallowing, and great debility, are extraordinarily re- 
covered from ; and, occasionally, when phthisis and the emaciation 
supposed to be its direct result, have reached an apparently hopeless 
point, the patient most singularly and inexplicably begins to recover. 
I have sometimes thought that an impression on the mind of the suf- 
ferer of the certainty of a fatal result, if the disease persisted, was the 



168 HYSTERIA. 

first link in the chain of events, marking a gradual restoration. I am, 
too, quite certain, that the progress of diseases destructive to life, and 
especially of phthisis, is often slower in the hysterical than in any 
other class. These and other considerations establish the extreme im- 
portance of an accurate and comprehensive knowledge of the symp- 
toms and varying aspects of hysteria. 

Diagnosis. — The remarks already made sufficiently prove how 
essential it is to the comfort of the patient, and to the reputation of the 
practitioner, that he should distinguish hysterical affections from more 
serious maladies. A mistake may lead to fatal consequences.. The 
regarding an acute disease as hysteria, and the conviction that hyste- 
ria is acute disease, are, although not equally, both dangerous errors. 
In the one, the only efficient treatment may be neglected till it is too 
late ; and in the other, the patient's life may be hazarded by measures far 
too active for her constitutional power. Happily, diseases decidedly 
inflammatory, are generally too strongly marked, to ad mil of fre- 
quent or serious doubt ; but examples of mixed disease, affecting vital 
organs, not unfrequently happen, in which the utmost circumspection 
is required. Here the practitioner must pause before he determines; 
he must not be misled by the anxiety of the patient, or by her convic- 
tion that, because she suffers pain and breathes difficultly, and has a 
quick pulse, and is herself alarmed, that active disease exists. But he 
must take each symptom alone ; he must contrast what he has per- 
haps "frequently observed in acute affections of the heart, brain, or 
lungs, or any other organ, with what he now sees ; and if there be 
even only slight evidence of the hysteric constitution, or any marked 
deficiency or peculiarity in the series of symptoms or course of the 
malady, there is sufficient ground for doubt. Under such circum- 
stances, he may prudently wait a little, and such delay will probably 
show that the worst symptoms are transient, and quickly change, and 
that there are intervals of ease and exacerbations, rarely or never 
seen in true inflammatory affections. 

A few cases thus studied from Nature herself, will furnish the ma- 
terials of correct diagnosis, and enable the practitioner, by and bye, 
to distinguish many of these dissimilar affections almost at a glance. 

Many attempts have been made to distinguish hysteria from epilepsy, 
the reason for which is obvious. Epilepsy is almost incurable — in the 
popular estimation, entirely so ; and although a confirmed epileptic is 
not insane, yet epilepsy is so often associated with imbecility, that one 
cannot wonder at the anxiety in protracted hysteria accompanied by 
severe fits, on this point. It must too be remembered, that epilepsy, un- 
like hysteria, is assumed to be hereditary. Dr. Marshall Hall ^ays, 
" that vast indeed is the distance which separates hysteria from epi- 
lepsy, yet how similar are the symptoms of the two diseases. There 
is one great distinction in hysteria: much as the larynx may be affected, 
it is never closed ; in the former w T e have, heaving, sighing inspiration 
— in the latter, violent, ineffectual efforts at expiration ; in the former, 
the cerebrum and the true spinal marrow are comparatively unaf- 
fected — in the latter, they are in a state of apoplexy and irritation." 

The hysteric fit is seldom so sudden as the epileptic seizure, nor is 
the unconsciousness and deprivation of muscular power so complete. 



HYSTERIA. 169 

In hysteria, the tongue is seldom bitten or protruded ; nor is there 
much, if any, escape of frothy saliva. An epileptic does not laugh 
and cry by turns, as in hysteria, but is in a state of fixed, vacant dis- 
tress. There is nothing feigned about epilepsy, and although hysteria 
cannot be regarded as a simulated disease, still it is often an exagge- 
rated one ; a remark entirely inapplicable to the more serious malady. 
After the paroxysm, the epileptic generally sleeps heavily ; and during 
its continuance the pupils are for the most part insensible to light ; nei- 
ther of which circumstances appertains to hysteria. An epileptic suf- 
ferer never remembers what has passed during the attack; a fact not 
at all uncommon in hysteria. Epilepsy is most frequent in men, in 
whom hysteria is exceedingly rare. Sydenham always inquired, whe- 
ther any particular disease affecting women had not first attacked them 
" after some disturbance of mind, or fretting." An affirmative reply 
doubtless strengthening the impression that the mischief was hysteri- 
cal. All attentive observers, even though they are not medical, must 
be struck with the vacant and almost imbecile impression left on the 
countenance by repeated attacks of epilepsy. Nor can we fail to con- 
trast the changeful, unquiet, and irritable expression of the hysterical, 
with the heavy and protruding eye, and the listless, dull physiognomy, 
of epileptic sufferers. 

Hysteria seems to single out and affect every organ, — every func- 
tion which belongs to the true spinal system. Like the emotions, it 
also affects the action of the heart, the secretions, and especially that 
of the kidney. Dr. Marshall Hall gives the following table of the parts, 
obviously under the dominion of the true spinal marrow, which are 
affected in this multiform disease. 

" 1. The larynx, — imitation of croup; apparently imminent suffo- 
cation. 

2. The pharynx, — dysphagia. 

3. The respiratory organs, — dyspnoea, cough, hiccough, retching, 
vomiting, &c. 

4. The cervix vesicas, — dysury, retention. 

5. The muscular, — trismus, tetanus, contracted hand, distorted foot, 
twisted legs, &c. The rest relates to emotion, which is the ' magna 
pars' of hysteria." 

Between hypochondriasis and hysteria, the distinction is generally 
easy, although in some of the inveterate and complicated examples of 
the latter disease, its approximation to hypochondriasis is very marked. 
Still there are positive differences. Hypochondriasis is for the most 
part a disease of men, and rarely attacks the young ; generally com- 
mencing with stomachic or intestinal derangement, and invariably ac- 
companied by dyspepsia. Spasmodic disorder, so common in hysteria, 
is rare in hypochondriasis, while in the course of the latter, cerebral 
affection often becomes permanently established. In hypochondriasis 
the distress is more real, and the disturbance of functions, especially of 
the chylopoietic, more extensive, injurious, and permanent. 

Treatment. — Few practitioners desire the management of hysteria. 
Its symptoms are so varied and obscure, so contradictory and change- 
able, that if by chance several of them, or even a single one, be re- 



170 HYSTERIA. 

lieved, numerous others almost immediately spring into existence ; the 
whole aspect of the case is unexpectedly changed, and thus week after 
week elapses, without any permanent advantage having been secured; 
the treatment which seemed to promise well at first is given up, and 
the patient becomes irritable and desponding. Imagine this picture 
with many like variations, and the portraiture of hysteria is complete. 
It is not a matter for surprise, then, that medicine and one physician 
after another should be discarded, and that the disease should so often 
be permitted to take its course, only to be interfered with when symp- 
toms of more than ordinary se verity' arise. Yet, although these remarks 
are true, there are examples which demand and are susceptible of bene- 
ficial medical treatment. Bat even these are not always easily under- 
stood, and rarely admit, for any lengthened period, of active, and cer- 
tainly not of indiscriminate remedies. 

That physician will treat hysteria best, who, having acquired a firm 
hold of the confidence of his patient, at once directs his attention to 
the influence of the mind and temper, and external things, on the ge- 
neral health ; including the state of the nervous system, both general 
and uterine, nutrition, intestinal actions, and sleep. From such inqui- 
ries, a knowledge may be obtained of the origin, course, and compli- 
cations of the malady; and a case exceedingly unpromising at first, may 
by treatment thus suggested and modified, be cured, or at least greatly 
relieved. But if such a course be neglected, and local symptoms alone 
be sought after and prescribed for, months and years may pass away, 
and the materia medica may be exhausted, without any permanent ad- 
vantage having been obtained. Nor can it be denied, that in many 
instances, even when the most judicious means have been perseveringly 
employed, they have failed, and the case has in despair been resigned, 
as one over which medicine has no control. 

To elucidate the treatment of the different stages and gradations of 
hysteria, the following arrangement may be adopted. 
1st, The treatment during the paroxysm. 
2d, The treatment during the interval. 

Of course, there are many circumstances which must limit and modify 
the remedial plan. These are, the origin of the malady, whether it de- 
pend on general nervous susceptibility, — or, as far more frequently, on 
uterine irritation, — or, perhaps, gastro-intestinal disorder — whether the 
hysteria is associated with general or local plethora or anaemia, — the 
prominence of single symptoms, or of a series, — and the means most 
likely to prevent a recurrence. 

Treatment during the paroxysm. — Probably in the majority of regu- 
lar hysteric fits, nothing is done, beyond the dashing of cold water on 
the face, and applying ammonia to the nostrils ; the patient is either 
laid down on the floor, or on a sofa, and is pretty much left to herself. 
She has often been thus before, and as recovery has taken place easily, 
it is fairly presumed that the same results will occur again, if she be 
not induced to believe, by over-attention, that the affection is either 
interesting or dangerous. Still it is important that the paroxysm be 
shortened, and that every measure be adopted to prevent accident or 
injury, from blows or falls. It has already been observed, that con- 
sciousness is generally retained, and enough of volition, excepting in 



HYSTERIA. 171 

convulsive and epileptic hysteria, to enable the individual to avoid 
danger; so that as the fit, by equalizing the circulation, and by re- 
moving nervous irritation, has upon the whole a beneficial effect, re- 
straint need form but a small part of the treatment. A lady, whom I 
long attended, always rejoiced when the fit was over, because it re- 
lieved her system generally, and especially her brain, from painful ir- 
ritation, which had often existed for several previous days. The 
means for preventing personal injury will suggest themselves to every 
prudent practitioner, and need not be mentioned here ; but it may not 
be irrelevant to remark, that in proportion to the degree of conscious- 
ness, the patient should be strongly urged to exert her own power of 
self-control, not only to shorten the continuance of the present, but 
also to prevent the recurrence of future attacks. Some individuals 
insist on the advantage of operating on the fears of the patient ; and 
it cannot be doubted, that beneficial results have followed ; but I have 
also seen alarming convulsions thus induced, and a regular safe form 
transmuted into anomalous and dangerous hysteria. Where the power 
of swallowing remains, half a pint or a pint of iced cold water will 
otten shorten a fit which might otherwise prove long and severe ; and 
in a confectioner's daughter, once my patient, this remedy alone was 
almost curative. Where there is flushing of the face, and any marked 
indications of general or cerebral fulness, the dashing cold water over 
the head and neck, and the application of evaporating washes, are 
highly useful. In spasmodic rigidity of the muscles of the head, neck, 
and upper part of the trunk, the power of deglutition is either greatly 
impaired, or altogether lost, and injections of cold water, or of spirit 
of turpentine and olive oil (vide form. 38, p. 99), may be employed. 
Diffusible stimulants, such as ammonia, ether, valerian, lavender, and 
assafcetida, are often given, where the power of swallowing remains, 
and there is no plethora ; occasionally they may be combined with 
hyoscyamus, camphor, morphia, or hydrocyanic acid ; the attack, 
however, is only shortened, not prevented, by these means. The 
prompt effusion of cold water over the face and head, when the fit is 
thought or known to be coming, and its injection into the rectum, and, 
according to Dr. Conoily, the exhibition of half a drachm of ipeca- 
cuanha, will often prevent its occurrence. It is rarely necessary to 
abstract blood during the fit, even in the comatose or epileptic form, 
excepting where the plethora with cerebral heat and throbbing exist, 
as the consequences of accustomed discharges now or lately suppressed. 
In such instances I have bled moderately with good effect, the patient 
declaring herself v to have been unusually relieved. Generally, how- 
ever, cupping between the shoulders, and this very rarely, will be 
quite sufficient.* The hot mustard-bath as high as the knees, is a 
good derivative, and it is scarcely necessary to enjoin the loosening 
of every tight part of the dress : on some occasions I have known the 
attack quickly terminated by ringing a loud and shrill sounding bell 
close to the ear for several minutes. 

* If cupping be practised, the scarification should he made as low down as possible, 
as the marks of the incisions are never lost — a point of some moment to those who 
are anxious about their appearance. 



272 HYSTERIA. 

General treatment during the intervals. 

Hysteria dependent on a morbid state of the uterine system.— Such 
cases are, I believe, more numerous than all others ; especially if the 
disorders to which uterine irritation gives rise, and which are often 
erroneously regarded as primary to the hysteria, be taken into account. 
Girls menstruating healthily, women married happily, and at a suffi- 
ciently early age becoming mothers, and nursing their children, are 
rarely to be enumerated amongst the hysterical; but girls, in whom 
chlorosis has delayed, and has perhaps, after all, permitted only the 
imperfect establishment of puberty and menstruation ; women married 
late, or after great delay, and who, from disparity of age or mutual 
dislike, bear children at long intervals ; and those who, either from 
the claims of fashionable life, or other insufficient reasons, do not 
suckle ; young widows, and the single: in all of whom some uterine 
derangement may be suspected, and in many ascertained to exist ; 
such individuals are the common subjects of the disease. Thus, if I 
were to select one organ as its peculiar seat, it would be the uterus. 
And if I were asked, what was the nature of the affection, 1 should 
express my belief that hysteria essentially consisted in excitement and 
irritation of the numerous and important nerves supplying the reproductive 
system. The facts just mentioned, the history of numerous cases, and 
their cure, frequently by marriage, and never without a diminution of 
the uterine disorder, corroborate these views. Pinel, Villermay, Lob- 
stein, Foville, Copland, and Addison most ably support them. Willis 
and Georget, on the contrary, ascribe hysteria to disorder of the brain; 
and in later years, Mr. Tate has contended, that it depends " on a 
morbid state of the spinal cord," but connected, nevertheless, "with 
disorder of the womb." Copland remarks very acutely, " that this 
' morbid state' is but a vague generic term, and that most probably, 
even when it is most prominent, more of altered sensibility than of 
vascular or structural lesion of this part of the nervous system, consti- 
tutes its essence." However this may be, attentive observation of the 
morbid phenomena, especially at their commencement, will show that 
the spina] affection is merely a consecutive and contingent disorder, 
and one by no means generally, or even very frequently observed. 
M. Andral says, " As to my opinion respecting the seat of hysteria, I 
repeat, that it is a nervous complaint, and that its seat is the nervous 
system." I am aware it may be urged, in opposition to these opinions, 
that structural lesions of the uterus are very common in females who 
have never had hysteria. Of the truth of this statement, to its full ex- 
tent, I am more than doubtful ; as I have accurately ascertained, both 
in hospital and private practice, that such individuals are by no means, 
especially in early life, so exempt from this common malady ; nor must it 
be forgotten, although there are exceptions, that these affections gene- 
rally do not occur till the reproductive faculty is either about to cease 
naturally, or has become seriously impaired by the progress of these or- 
ganic changes. 

The precise treatment to be pursued, will mainly depend on the 
character of the uterine disorder. If chlorosis exist, those measures 



HYSTERIA. 173 

must be adopted which are calculated to improve the general health, 
and which are fully described in the first chapter of this work. If 
amenorrhoea be the prevalent condition, its cure must precede the at- 
tempt to remove the hysteria. Dr. Conolly thinks that amenorrhcea 
is not a frequent concomitant of the affection, and perhaps he would 
be right, if he were to except the amenorrhoea of delicate and irritable 
females, in whom hysteric fits are common. Most frequently menor- 
rhagia alone, or complicated with leucorrhoea, connects itself with 
hysteria, and little can be done for the cure of the latter affection, till 
the healthy uterine function is restored. In the chapter devoted to 
these diseases the appropriate remedies are pointed out. Sometimes 
a really irritable uterus originates and maintains the hysteric paroxysm ; 
in which case there will be pain behind the pubis, and over the sa- 
crum, and at the point of the coccyx ; but especially will there be more 
or less acute suffering on pressure of the cervix uteri, whose congested 
and partially indurated condition may induce a fear, that organic 
disease will ultimately occur. Cupping on the loins, leeches to the 
perinaeum and about the verge of the rectum — but above all, leeches 
to and scarifications of the cervix itself, will afford the most certain 
and effectual relief. The poppy hip-bath at 96°, the patient remaining 
in it for an hour every evening, and a suppository of opium, or bel- 
ladonna, at bed-time (vide formulas), are admirable remedies. 

Hysteria dependent on plethora. — This is not a common form, but ex- 
amples do somewhat frequently occur, where a certain amount of 
plethora exists in connexion with the hysteria, and which may be 
traced to scanty menstruation; a suppression of accustomed evacua- 
tions or discharges; the injudicious cure or spontaneous disappearance 
of eruptions ; the neglect of proper exercise ; much confinement to the 
house, and a too nutritious diet. It is not difficult to enforce the mea- 
sures immediately necessary : one or two bleedings from the arm, to 
a moderate extent — cupping between the shoulders — smart purging 
and spare diet, will avert the dangers of impending hysteria, either of 
the epileptic, comatose, or apoplectic forms. Subsequently, the plan 
must be modified, and a few leeches once a-fortnight or more frequent- 
ly, behind the ears ; perhaps an issue in the arm, and a mercurial 
purgation once or twice a-week, will suffice. But animal food must 
still be taken only once in the day, early rising, sleeping on a mattress in 
a well-ventilated apartment, the daily use, or two or three times a-week, 
of the tepid or cold shower-bath, and more than all, regular walking exer- 
cise, must be enjoined. Already have the evilsbeen pointed out of walk- 
ing or other exercise taken to excess ; great and injurious fatigue is 
thereby induced : the patient thinks she cannot endure such an effort 
again, and she either gives it up altogether, or walks only at distant 
intervals ; or if her station and means permit it, she rides henceforth, 
either in a carriage or on horseback, neither of which confers half the 
good to be derived from that exercise " which Providence evidently 
intended that man should take by means of his own limbs, and not 
those of another animal." Often do female servants become the sub- 
jects of these species of hysteria, in consequence of a sudden change 
from the hard fare and exertions of a country life, to the more animal 
12 



274 HYSTERIA. 

and luxurious diet, softer beds and close apartments, presented to them 
in the houses of the rich. 

Dr. Parry strenuously urges as an evidence of weakness of mind, 
the abandonment by the higher ranks of nearly all voluntary exercise, 
and the evils which must ensue from such frequent confinement in 
warm rooms, during so many hours of the night; which, as he remarks, 
" always imply so much time taken from the day, and from the anima- 
ting but little heeded effects of light." He also notices the admonitory 
fact, " that singing birds and lap-dogs, which are confined and highly 
fed, are subject to the whole train of nervous affections, as palpitation 
of the heart, breathlessness on slight motion, hysteria, convulsions, 
epilepsy, hemiplegia, and apoplexy." 

Hysteria dependent on debility. — It is in the management of this spe- 
cies of hysteria, that the fullest scope is afforded for the exercise of 
medical acumen. Local vascular excitement or congestion in the ce- 
rebrum, or in some portion of the spinal marrow, may coexist with 
constitutional debilit) ; a condition requiring for its relief a nice adjust- 
ment of treatment. Thus, while it is essential to relieve an excited 
brain, or to unload the vessels of a congested portion of the medulla 
spinalis, the local depletion and counter-irritation must be the excep- 
tions to the general plan of nutritious diet and tonic treatment. Were 
we, on the contrary, in addition to these local measures, to enjoin but 
little food, and drastic or saline purgatives, instead of relieving, we 
should aggravate the malady. 

To modern pathology we are indebted for these important facts; 
nor have they been neglected by intelligent practitioners. The treat- 
ment of this species of hysteria has of late been conducted on right 
principles — being neither entirely tonic, nor entirely depletive ; for it is 
now fully understood, that local congestion may arise from, and ag- 
gravate a constitutional disorder, dependent almost entirely on debility. 
To employ, therefore, irrespectively of such knowledge, either one plan 
or the other singly, would be to disregard these illustrative facts. 

As to the stomachics, tonics, and aperients best suited to » hysterical 
debility, I must again refer the reader to the chapter on chlorosis, 
where he will find ample information. The waters of Eath, Pyrmont, 
Baden, Seltzer, Carlsbad, and various others, have long been recom- 
mended, and Sauvage particularly enjoins in chlorotic hysteria the 
tepid, sulphurous waters of Cauterets and Bagnaules, four pints daily 
for three days, and a bath on the fourth. The older physicians fre- 
quently prescribed a milk diet, and I have several times witnessed its 
good effects. Sydenham thought great good was obtained by the in- 
fusion of various bitters in canary wine, and he advised hysteric pa- 
tients to drink it largely at night before going to bed. He further says, 
" that the whole body was much strengthened, and such as were before 
cachectic became fresh-coloured and brisk thereby." Horse exercise, 
, change of scene and climate, sea bathing, and varied but active em- 
ployment, have been already dwelt upon. Nor must it be forgotten, 
that powerful mental impressions often control and relieve, and occa- 
sionally cure the disease. A voyage or a journey full of romance and 
adventure ; such an alteration of circumstances as may expose to more 



HYSTERIA. 175 

of the contingencies and difficulties of life, rarely fail to be beneficial. 
In the French revolution, the ladies of Paris, and in the Irish rebellion, 
the women of Ireland, subjected as they were to alarming excitements, 
forgot and laid aside their hysterical affections, and Cullon noticed 
similar effects in the ladies of Scotland, in the civil war of 1745-46; 
and Dr. Rush also, in a curious paper " On the Influence of the Ame- 
rican Revolution on the Human Body," observes, that many hysterical 
women who were much interested in the successful issue of the contest 
" were restored to perfect health by the events of the time, change of 
place, occupation," &c. There are, I suppose, few practitioners who 
could not adduce similar examples, and who could not corroborate the 
fact, that luxury and refinement almost invariably aggravate the 
disorder. Frank remarks, u that the wives of merchants are affected 
with hysteria in flourishing times — but when reverses come they have 
no time to be ill." 

Hysteria dependent on gastro-intestinal disorder. — This section need 
not detain us long, as in other parts of the work it has been fully although 
incidentally discussed (vide chlorosis and amenorrhea). There are, 
however, two symptoms attendant on this form of the malady which 
really deserve especial attention, viz., distressing intestinal flatus, which 
is exceedingly common, and tension and tenderness of the abdomen ge- 
nerally ; but particularly of the hypogastric region, which, although 
frequent, is more rare. 

For the relief of the latter condition, I have long been in the habit of 
applying six or eight leeches, either once, twice, or even more fre- 
quently. Conolly has remarked, that where the lower part of the 
abdomen is tumid and uneasy, the leeches may with more advantage 
be placed around the orifice of the rectum. The distress induced by 
the flatulence, occurs generally after taking food, and deserves atten- 
tion, not more from its accompanying painful distention, than from its 
so frequently inducing the hysteric fit. A small tumbler of water, as 
hot as it can be swallowed, during or immediately after the meal, with 
some powdered ginger, a little brandy, sal volatile, or a few grains of 
cayenne pepper entirely dissolved in it, seldom fail to afford relief; 
friction by the hand or flesh-brush over the abdomen ; and in really 
severe cases, the injection of a pint of hot water into the rectum, with 
or without assafcetida, may be tried. 

It is scarcely necessary to do more than mention the importance of 
a simple, nutritious, and a somewhat stimulating diet ; and if there be 
any suspicion that the hysteria is connected with the presence of 
worms, anthelmintics may be used, if the dietetic plans prescribed are 
not successful. In some cases, confined bowels seem to be the great 
cause; and there are few things more difficult of accomplishment, 
than, by even the most judicious management of diet and medicine, to 
bring the intestinal actions into a regular and healthy state : still the 
effort must be made. The colon often contains large and unsuspected 
accumulations of vitiated faecal matter, by which many hysteric parox- 
ysms are induced : nor is it by any means an easy matter to excite the 
patient's attention sufficiently to prevent a repetition of this mischief. 

Treatment of symptoms peculiar to Hysteria, — Enough, perhaps, has 



176 HYSTERIA. 

been already said to convince the reader, that he must not, in his admira- 
tion of scientific and comprehensive treatment, reject, in the manage- 
ment of particular hysterical symptoms, what maybe deemed empirical 
modes of relief; for often, when the general health has been greatly 
improved, the hysterical headache, the hysterical asthma, and those 
hysterical and almost incurable pains in the side, described by all wri- 
ters, still persist. Villermay, regarding hysteria as exclusively of 
uterine origin, most improperly neglects the state of other viscera, and 
all other than uterine symptoms. Georget, on the contrary, entirely 
negatives the uterine theory, and locates the disease in the brain, and 
hence most erroneously concludes that it is useless and idle to attend 
to the stomach, the bowels, the heart, or the uterus. The treatment 
of the former physician, therefore, is partial and inefficient ; while that 
of Georget is absolutely absurd, for he gravely prescribes bread pills 
and water, and tisanes equally mild and harmless, for every form of 
the malady. It is hardly possible to believe that these able practi- 
tioners can have seen much of the disease, or, if they have, they must 
have observed it under the influence of the strongest prejudice. 

For the measures most frequently affording relief in hysterical head- 
ache, I refer the reader to the chapter on Chlorosis ; only premising, 
that certain remedies and plans of treatment ought not to be given up 
till they have been fairly tried, and even then, or when their advan- 
tageous effects appear to have been exhausted, their resumption at a 
subsequent time is often beneficial. At pages 24 and 43, I have care- 
fully described the various forms of these hysterical headaches ; and I 
beg to observe here, that of no other ailment connected with the dis- 
ease, does the patient complain so grievously as of this, especially 
when' it is protracted or almost constant. Several authors speak 
highly of the ammoniated valerian : in the following form I have often 
found it afford great relief: — 

&. Tinct. Valerianae Ammon. Spir. iEth. Sulph. C. Spir. Lavand. C. 
aa, gss. Tine. Hyoscyami n\,xx. Mist. Camph. £x. M. ft. Haust. 
*2da vel 3tia quaque hora sumendus. 

The good effects are increased by its being taken as hot as the pa- 
tient can swallow it. 

R. Tinct. Valeriana ^j. Acid. Sulph. dil. "Ix. Tine. Cinch. £j. 
Aquse Puree ^viij. M. ft. Haust. bis, terve q^otidie capiendus. 

Many other similar medicines might be suggested, but it is scarcely 
necessary to detail them here ; the practitioner will soon discover the 
very intractable character of the complication, and he will be on the 
alert either to find out new remedies, or novel combinations of old 
ones. In two instances, where every other measure failed, a grain 
and a half of blue pill, night and morning, were given sufficiently long 
to produce slight affection of the gums, and with decided relief to the 
headache. Occasionally the pain is so severe as to induce the patient 
to think that she shall lose her senses. In such examples, or where 
there is any threatening of phrenitis, a darkened room, absolute quiet, 
narcotics, hot or cold applications to the head (the former being fre- 



HYSTERIA. 177 

quently the most beneficial), and the encouragement of menstruation by 
mustard hip and foot-baths, are appropriate means. 

After all, there is no complication more difficult to cure, even to re- 
lieve, than hysteria attended by pain in the left side. Mr. Tate has as- 
sociated it with tenderness or inflammation of the spine and uterine 
disorder, giving the precedence to the former state. Doubtless, there 
are many corroborative cases ; but certainly in some very bad and long- 
continuing ones, I have failed to discover throughout the whole column 
any indications of inflammation of the medulla or its coverings. To say 
that uterine derangement exists, is only to repeat what every one knows 
to be almost universally true. 

Mr. Tate has furnished some very instructive and interesting cases, 
where there was great tenderness of the dorsal spine, and about the 
sacrum, and which were greatly relieved by the local treatment he 
pursued. But even this pathology, which seemed to promise much as 
the result of direct treatment, has shared the fate of previous theories. 
The affection of the spine, so well pointed out by this author, is not 
always inflammatory; frequently it does not pass the limits of excited 
sensibility, and several times I have seen the hysterical symptoms ex- 
asperated and the general health seriously impaired, by the leeching, 
blistering, and various kinds of counter-irritation, which, in obedience 
to this new and scientific view, were strictly and perseveringly, yet 
erroneously practised. Of course, the vertebral column ought to be 
carefully examined, and local measures must be beneficial, if there be 
marked tenderness and puffiness around one or several of the spinous 
or transverse processes. But even here it is necessary to be on our 
guard: if, during the examination, the pressure made either by the 
finger or the handle of a common key be, as I have often known it, 
unnecessarily heavy and sudden, there are few susceptible females 
who would not by their wincing give proof of pain. But the exami- 
nation must be more carefully conducted, and if isolated tenderness 
and puffiness be then discovered, the complication really exists. Mr. 
Tate thinks that the hysterical pain in the side is seated in the inter- 
costal nerve, and sometimes in the nerves of the heart itself. But the 
pain is in many of these cases on the right side, under the margin of 
the ribs; and all allow the non-inflammatory character of these pains, 
although, it cannot be denied, in plethoric subjects, that moderate de- 
pletion may sometimes do good. There are no cases less satisfactory; 
for neither local treatment nor medicine seem to avail much for their 
relief. Opium plasters, with or without belladonna, shampooing, acu- 
puncturation, the tartar-emetic ointment, and various narcotic embro- 
cations, have all been employed, occasionally doing some good, but 
more commonly attended with only a very limited amount of benefit. 
The following liniment deserves trial — in my own practice it has 
relieved these peculiar pains quite as much, if not more, than any 
other: — 

R. Ether Rect. Sp." Camph. Tinct. Opii, Tinct. Lytse, a a &iv. M. ft. 
Lin. Frequenter quotidie partibus affect, bene infricendum. 

On electricity and galvanism as remedial agents, much confidence 
is not placed; although of late, in several affections dependent on or 



178 HYSTERIA. 

intimately associated with this malady, the former has been usefully 
employed at Guy's : nor can there be a doubt, where the hysteria is 
connected with a torpid or amenorrhceal state of the uterus, that the 
paroxysm and its immediate results have been materially relieved, 
and in some cases entirely cured, where menstruation had appeared 
under the influence of the electric treatment. In chorea, so often con- 
nected with hysteria, and in hysteric epilepsy, occurring in women in 
whom the uterine functions were suspended, electricity, by restoring the 
catamenia, has been of marked and material service. 

It is not unimportant to observe, that although marriage often cures 
hysteria, women who have long suffered from its effects, rarely make 
good nurses. Doubtless there are exceptions to this fact; nor is it in- 
tended to be urged, that such women cannot suckle at all; nor that they 
may not occasionally be benefited by lactation. But where, prior to a 
late marriage, hysteria has existed for years, in association with extreme 
susceptibility, peevishness of disposition, and thinness of person, it is 
for the most part undesirable, that such mothers should suckle their 
offspring. The milk is often disordered, the child's digestive system 
is thereby deranged, and a predisposition to nervous disease may be 
communicated. 

Preventive treatment. — Where a tendency to the disease is evident, 
or where one or several decided hysteric seizures have occurred, it 
is important that every prophylactic measure should be early and fully 
adopted. 

The remarks on the physical education of female youth (pages 29 
and 30), have a distinct reference to this important subject; and it 
cannot be too strongly urged, that nature and common sense are much 
better arbiters in every matter relative to female health, than fashion and 
a too refined taste. Of all the influences capable of moulding the fe- 
male constitution, there are none so powerful as light, air, food, and 
exercise; and certainly in reference to the three latter, nothing can be 
more at variance with propriety than our natural customs. It were 
easy to censure the way in which female education is conducted; but 
it would be to little purpose, till such plans are adopted as shall in- 
sure a higher appreciation of physical health and vigour. Happily of 
late some degree of reformation is observable ; and the young ladies 
even in our fashionable boarding schools are beginning to realize its 
blessings. Animal food, and not farinaceous puddings and slops, whole- 
some malt liquor instead of water, tea, or bad wine, running, jumping, 
and vigorous play, are now occasionally heard of without being, at once, 
condemned as fit only for the vulgar. By and by, it is to be hoped, 
that a sounder education will be built on these natural principles; and 
instead of days and weeks, devoted as they now are, to music, absurd 
accomplishments, and romantic nonsense, some hours at least, daily or 
weekly, will be given up to history, literature, and the economy of every- 
day life. 

In bringing this chapter to a conclusion, I feel that I may have 
dwelt longer on the subject than its real importance might, at the first 
view, seem to justify. But, when it is remembered, how extensively 
this incubus of the female habit prevails, how many diseases it simu- 



HYSTERIA. 179 

lates, and how many it masks, — how wide a field it throws open to 
the dishonest practices of empirics of every grade, — and yet how fre- 
quentl}*, by a comprehensive and accurate acquaintance with its pro- 
tean forms, alarm may be dissipated and inapplicable remedies dis- 
carded, — I shall not perhaps be deemed justly censurable for the space 
thus appropriated. The end and aim has been, to point out the uterine 
functional origin of hysteria, and, without a too prolix detail, to convince 
the reader, that a morbid or perverted nervous influence, the very essence 
of the malady, may and often does change the aspect,. and thus perplex 
the diagnosis of every female sexual disease. 



CHAPTER XL 

OF THE IRRITABLE UTERUS, OR HYSTERALGIA. 

Definition. — A permanent and painful sensibility of the uterus, and 
especially of its neck ; often accompanied by increased frequency of pulse, 
a dry, hot skin, and generally, in protracted cases, with gastric and renal 
derangement. The disease usually occurs during the middle period of life, 
and commonly prevents conception. It is exceedingly difficult to cure, even 
to palliate; and, it is said, that it is neither attended by, nor tends to pro- 
duce change of structure. 

History and Symptoms. — The disease is in fact a constant dysmenor- 
rhea, and for the first masterly description of it, we are indebted to 
Dr. Gooch. A narration of the symptoms of painful menstruation in 
its neuralgic form, would, with slight alterations, suffice for irritable 
uterus. It does not occur to the very youthful ; the earliest time that I 
have seen it being in the twenty-third year, although Dr. Dewees men- 
tions an example of a young lady of only eighteen, where all the symp- 
toms were present, even to the prolapsed state of the uterus. Generally 
it is a disease of married life, and I have never known an instance 
where pregnancy occurred during its continuance. Single women, 
after thirty, or at the approach of the period of catamenial decline, and 
widows, may be its subjects. 

The local symptoms are pain in the lowest part of the abdomen, ex- 
tending round the brim of the pelvis, and also in the loins ; and while 
it may be truly said, that these pains never entirely cease, they are 
easily exasperated by mental emotion or bodily excitement. Often 
have I known the attempt to go up stairs, a short walk, an injudicious 
ride, or even sitting upright or standing only for a few minutes, induce 
severe lancinating pains, in and about the pelvis, lasting for many hours. 
Sometimes the whole of the vulva and the vagina, especially at its ori- 
fice, are slightly swollen; and when the disease is thoroughly confirmed, 
any movement by which the neck of the uterus is brought into sudden, 
jarring contact with the surrounding parts, excites severe suffering. 
Hence defecation, if it be difficult, or even the evacuation of the blad- 
der, are dreaded events. Leucorrhcea is a frequent attendant ; and at 
this time, I have under my care a patient, where its amount and cha- 
racter are dependent on the intensity and continuance of the pain. If 
the sufferings have for a few days been unusually severe and uninter- 
mitting, the discharge becomes copious, thick, greenish, and offensive: 
whereas, after a period of comparative ease, the secretion is only mu- 
cous and transparent. 



• IRRITABLE UTERUS, OR HYSTERALGIA. 181 

The uterus is almost always a little lower in the pelvic cavity than 
natural, and by some authors it is said to be even constantly prolapsed. 
An external examination of the lower part of the abdomen gives pain; 
and if the finger be pressed behind the pubis, and round the pelvic 
brim, a paroxysm is not unfrequently induced. But it is by an 
examination of the neck of the uterus that we discover the real na- 
ture of the malady. It cannot be said, that the body of the organ 
is free from morbid tenderness, but the sensibility of the cervix is often 
so exquisite that the patient shrieks, and is thrown almost into a fit of 
hysteria, if it be rudely touched ; and on several occasions, by patients 
at Guy's, I have been requested to forego any renewed examination, 
because so many hours elapsed before the intense suffering subsided, 
even after the slightest pressure. Dr. Gooch believed that the tender- 
ness was confined to the uterus, and that the finger might be pressed 
against the sides of the vagina without causing uneasiness. This 
statement my experience has not confirmed, having observed frequent- 
ly a more than ordinary degree of sensibility and heat in this canal. 
In acute inflammation of the cervix uteri, a much less common dis- 
ease, the observation is, I think, perfectly true ; as then pressure on 
the vagina, immediately contiguous to the neck, or on the body of the 
uterus, is borne without any suffering at all. In irritable uterus, the 
cervix is often somewhat shortened and expanded, and occasionally 
puffy and swollen, and the lips of the os are more than naturally closed. 

Dewees especially notices as having occurred in all his cases a pul- 
sating, throbbing, or fluttering sensation within the vagina or in some 
part of the pelvic cavity, always disagreeable, though not constantly 
present, and sometimes interrupting sleep. Such a symptom has not 
existed in marked degree in the examples I have seen ; but in several, 
the throes of the uterus have been painfully severe. 

Constitutional Symptoms. — There is usually vascular excitement, and 
after a time the pulse becomes habitually quicker, softer and com- 
pressible ; and sometimes in plethoric women, harder and fuller. Even- 
ing fever occurs with a flushed cheek and hot skin ; there is also 
headache, dyspepsia, and a capricious appetite. The urine is often 
high-coloured, scanty, and voided with pain ; and according to some 
authors, it is strongly odorous, and when at rest, throws down a large 
deposit. The suffering attendant on the disease is more/severe and 
paroxysmal prior to, and during, or after menstruation, l/it the regu- 
larity of the secretion is not seriously interfered with : its quantity is 
usually diminished, and it is often pale and watery, but rarely if ever, 
profuse. The constant uneasiness, and the frequent exacerbations, 
even independently of motion, soon compel almost entire confinement 
to the sofa : hence the want of exercise and fresh air, the worrying 
and almost incessant pain, and the constant use of narcotics, sooner or 
later break down the general health, and a languid circulation, con- 
stipated bowels, dyspepsia and emaciation ensue. 

Pathology. — Dr. Gooch's opinion, that the irritable uterus sustains, in 
reference to inflammation of the organ, the same position as irritable 
tumour of the breast, and irritable hysteric affection of the joints, to 



182 IRRITABLE UTERUS, OR HYSTERALGIA. * 

inflammation of those parts; and that it consists in a permanently pain- 
ful state of the viscus, but that it is neither accompanied by nor tends 
to produce change in its structure, require for their establishment as 
facts, more proof than has hitherto been adduced. This accurate ob- 
server founded his views on analogy, and on the lengthened period of 
ten years, during which, having carefully watched the progress of 
certain cases, he found the uterine organization still unaltered. The 
analogical part of the opinion is unsatisfactory, and must remain so 
till the nature of hysteria is developed, and till the affections from which 
this pathology is deduced are more clearly proved to be not at all de- 
pendent on inflammation. That the disease in question should be re- 
garded as a modified inflammation of the cervix uteri, is a view, in 
accordance not only with symptoms, but with the results of the most 
successful treatment. It is difficult to understand, that there shall be 
redness, which I have several times seen by the speculum, heat, per- 
manent pain, and tenderness of the neck of the uterus, a glandular 
part, without believing that its vascular and nervous structures, shall 
have undergone some change. Judging also from the marked relief 
afforded by cupping, leeching, aperients and spare diet, in Dr. Gooch's 
own cases, what more tenable and satisfactory conclusion can be ar- 
rived at, than that the so-called irritable uterus is really dependent on 
sub-acute or chronic inflammation ; a position, the truth of which is 
fully substantiated by those changes of structure, which, although 
slowly, and not till after many years, have nevertheless occurred, in 
cases which, till then, were regarded and treated as examples of irri- 
table or neuralgic disease. 

It is scarcely practicable to substantiate by examinations after death, 
the opinions now advanced ; because a fatal result very rarely, if ever, 
occurs; although, I presume that morbid conditions of the nervous 
system may thus terminate, without having induced any manifest le- 
sions of structure. But had the life of the distinguished physician to 
whom I have so often alluded, been prolonged, he would probably 
have been convinced, that induration, subsequent softening, and de- 
struction of this particular portion of the organ, did occur in this sup- 
posed functional malady. Dr. Dewees urges that an examination be 
made, should an opportunity present, as he thinks " that more derange- 
ment of structure would be found than appears to be allowed to exist, 
for we have met, he says, with several cases in which the size and 
form ot the neck of the uterus were much altered from their natural 
condition." Dr. Robert Lee also remarks, that " it is maintained by 
some that all the symptoms of chronic inflammation of the uterus 
may be present without inflammation, or without any sensible de- 
rangement of the uterus. This view does not, however, rest on ac- 
curate and extensive pathological research ; and the heat, swelling, 
and exquisite sensibility of the neck and body of the uterus, prove 
that in the disease, or group of diseases, described by Dr. Gooch 
under the name of irritable uterus, a state of the organ exists closely 
allied to inflammation or congestion. In more than one case which 
had been considered and treated as simple irritability of the uterus, 



IRRITABLE UTERUS, OR HYSTERALGIA. 183 

without inflammation, organic disease of a malignant nature was sub- 
sequently developed. The presence of fibrous tumours in the walls of 
the uterus, has likewise in some individuals given rise to that peculiar 
series of symptoms which has been described as characteristic of irri- 
tability of the uterus, without inflammation or disposition to a morbid 
alteration of structure." In a poor woman of the name of Turton, 
long under my care at Guy's Hospital, I had an excellent opportunity 
to test the truth of these opinions. She was an out-patient for three 
or four years, and during the whole period was suffering from irritable 
uterus. ' Constantly I pointed out her case to the pupils, as an excellent 
example of this affection. Numerous remedies were tried ; and some- 
times relief was obtained, but more frequently the various measures 
independently of narcotics, did little or no good. At length, after 
nearly six years, induration occurred. She became an in-patient, and 
the entry by the clinical clerk in September, 1838, is as follows:— 
"The cervix is extensively destroyed by ulceration, and is also indu- 
rated." Nor may it be irrelevant to notice, that Mr. Lever has found 
that one of the occasional results of dysmenorrhcea, is structural lesion. 
Dr. Gooch, indeed, allows that the disease consists in a state of the 
uterus, similar to dysmenorrhcea, only permanent instead of occasional. 
If this be so, is not the probability increased, that his pathology of this 
presumed disease of irritation is erroneous ? He further says, thus 
proving that he doubts the correctness of his own opinions, that the 
cases may be arranged in three classes — " in one of which congestion 
is an essential part ; in another, congestion may be absent ; while 
another may consist of those interminable cases which nothing relieves. 
In these there may be some disease of structure, in a part of the uterus 
out of reach of examination by touch." 

Probably irritable uterus may be hereditary. Several times I have 
found on inquiry, that the mothers of the sufferers had been similarly 
affected ; and in a case I lately saw with Sir James Clark, the_ lady 
assigned as a reason w^hy she ought not to submit to scarification of 
the congested cervix, that as her mother had suffered severely all her 
life from the disease, nothing would do her any good. In three in- 
stances under my own observation, the malady has gradually disap- 
peared with the decline of the catamenial function, without leaving as 
its consequences any morbid condition of the cervix. 

Causes. — It is easy to enumerate many circumstances which directly 
excite the disease, but it is more perplexing to point out the causes 
which predispose to it. Most of the patients I have seen w T ere highly 
susceptible, in common parlance "nervous persons;" but the disease 
is by no means confined to this class, the hale and healthy occasionally 
suffering from its aggravated forms. Most authors, however, concur 
in the fact that dysmenorrhcea frequently precedes it. 

Any undue bodily exertion, especially during menstruation, or after 
abortion, may bring on the affection, more particularly if there be a 
latent, although unappreciated predisposition. In one of my cases, its 
first attack was attributed to a long ride on horseback, in the fourth 
month of pregnancy : and violent jolting, or too long standing in the 
erect posture, may at any time produce it. A too powerful astringent 



184 IRRITABLE UTERUS, OR HYSTERALGIA. 

injection for the cure of leucorrhoea, and cold ablution of the vulva, 
and a sudden stoppage of menstruation from alarm, have each occa- 
sioned it. Excessive sensibility alone, may determine its first appear- 
ance, and in several examples, together with a painfully tender condition 
of the vagina, the disease was attributed to marriage ; but there are 
also many instances where distinct and positive causes maybe adduced. 
Lately I w T as quite satisfied, that the affection dated its commence- 
ment from prolapse of the womb, which had remained undiscovered 
several months: a pessary was introduced, and every distressing symp- 
tom was quickly relieved. Several times at Guy's it has been ascer- 
tained to depend on hard or fibrous tumours in or near the cervix, and 
a puckered and hard condition of this part has not unfrequently been 
complicated with its worst symptoms. On one occasion, a tender and 
slightly indurated and contracted os was the only appreciable cause ; 
and gradually did the symptoms decline, when by depletion, the inter- 
nal and local use of iodine, the warm bath and sexual abstinence, 
these unhealthy conditions had been removed. Dr. Ingleby has made 
some interesting observations on the affection, and as the following 
are confirmatory of my own experience, I shall quote them in his 
words: " Within the last twelve years I have seen a great number of 
cases of the disease termed irritable uterus, and I have kept notes of 
seventeen of them. Three of these were unconnected with any ap- 
preciable cause : one w T as attended by descent of the ovary into the 
pelvis ; one by descent of the uterus soon after marriage ; one origi- 
nated in extreme distention of the uterus during pregnancy ; seven fol- 
lowed delivery ; four were connected with fibrous tumours. Of this 
number, it is material to observe, that in several of the cases there was 
one prominent symptom, namely, excessive irritability of the vagina." 

Diagnosis. — From neuralgic dysmenorrhea, the irritable uterus will 
be distinguished by the constancy of the attendant suffering. From acute 
inflammation of the cervix, by the absence of swelling, heat and throb- 
bing; and from chronic inflammation, tending to disorganization ; by the 
history of the case, its intimate connexion with deranged menstruation 
(the function with which uterine organic lesions rarely interfere, even 
throughout their whole course) ; by the absence of discharges; by the 
duration of the malady ; and by the slight alteration of the cervix itself, 
as compared with the amount of suffering. It has been mistaken for 
common prolapsus, but although the descent of the uterus, so frequent 
in this disease, may be entirely removed by the recumbent posture, 
still unlike what obtains in the former affection, the pain, which in 
simple prolapsus is entirely removed by replacement, is, in irritable 
uterus, only palliated. 

Prognosis. — This is invariably favourable to life, but an early re- 
covery must not be promised. It may be truly said, that the disease 
admits of great relief, but let it be urged, that this is seriously dependent 
on the self-denying fortitude of the patient. Without this, for no af- 
fection is so prone to return, the skill and assiduity of the practitioner 
will avail but little. 

Treatment.— If the reader will refer to the chapter on dysmenor- 
rhea, he will there find a full detail of the various remedies, which are 



IRRITABLE UTERUS, OR HYSTERALGIA. 185 

alike applicable to both affections. In the management of irritable 
uterus two indications must be observed : viz., to mitigate local suffer- 
ing, and to sustain and improve the general health. 

In addition to all the medical means, absolute repose in the hori- 
zontal posture must be enforced, not for a few w T eeks only, but for se- 
veral, perhaps for many months. Let it, however, be understood, that 
arrangements should be made to carry the patient into the open air, 
and if possible, to place her on the sea-coast. Sailing, exercise in the 
recumbent posture, and quietude, are essential. Active purgation must 
be interdicted, as it never fails to induce and exasperate the pain. A 
generous, but not a stimulating diet ; milk in every form in which it 
can be prepared ; steel, in moderate and long-continued doses ; narco- 
tics varied and in minute quantity ; claret and bitter ale, are amongst 
the best and most important remedies. Low diet, close confinement 
within doors, drastic aperients, and even frequent small bleedings, must 
be carefully avoided. Several times within the last two or three years 
I have employed scarifications, as first recommended and practised by 
the late Mr. Fenner. A suitable speculum must be carefully intro- 
duced into the vagina, by which the os and cervix will be brought 
fairly into view ; then by a cornea knife passed down the tube, seven 
or eight crucial scarifications may be made, from which frequently 
three or four ounces of blood will be obtained. I have never known 
the patient complain of pain from these incisions, nor am I aware 
that any difficulty or delay has retarded their cicatrization. In two 
patients of Mr. Fenner whom I several times visited, this treatment 
had been curatively employed ; and judging from their and his ac- 
count, they were both of them aggravated forms of the disease. In 
several of my own cases this method of depletion has proved most 
successful, not only in immediately relieving the characteristic pain, 
but in restoring the uterus, and especially the cervix, to a more healthy 
state. Where there is no evidence of congestion, or of increased vascu- 
larity, the scarifications ought not to be made; but I think the irritable 
uterus is rarely unattended by this morbid state of cervix. Pessaries 
have long been recommended, where there is decided prolapsus ; but 
I am not aw T are that they have been employed in the absence of this 
state. ^ I am now convinced, after a good many trials, that where even 
there is no marked uterine descent, they will often give great relief, pro- 
vided the vagina is not unusually tender and irritable. In several in- 
stances every other measure was fruitlessly employed ; but the use of 
a circular box-wood pessary, for three or four months, seemed really 
to have cured the affection. 



Case 40. 

irritable uterus — scarification of the cervix.' 

December, 1838. I was requested by the late Mr. Fenner, of Pentonville, to 
visit Mrs. , set. 39. She had long suffered from the most aggravated symp- 
toms of irritable womb, and occasionally the paroxysms were so severe as nearly to 
deprive her of reason. The throbbing and pulsating sensation, so pointedly alluded 
to by Dewees, was most painful, and often interrupted, and sometimes entirely pre- 



186 



IRRITABLE UTERUS, OR HYSTERALGIA. 



Tented sleep. She had been robust, and -embonpoint," till the occurrence of the 

disease two P year S previously ; but so little relief had been obtained, and the sufferings 

vvere so unpermitted, tbatshe had become emaciated and irritable, and was constantly 

7y*Z on the sofa ; the -great trouble of her life being that occasionally she was com- 

pelled to move." On examination, we found the uterus highly congested and its 

ce vix hard, of large size, and very tender : the vagina too, throughout its whole ex- 

enT was morbid l/ sensitive, and even gentle pressure caused prolonged and severe 

sufferings. The disease had succeeded an abortion two years before. At that time 

here was considerable hemorrhage, and the gradually increasing tenderness of the 

nternal genitals had for many months induced her to live -absque manto. Men- 

stuation^invariably aggravated her misery, and there was sometimes "Bumble 

leucorrhoeal discharge. Altogether, it was as distress.ng an example of the affection 

as I had ever witnessed. „;„u«. 

On the day succeeding our first visit we again met and I made seven or eight 
scarifications in the way already described; and nearly four ounces of blood, by mea- 
sure were obtained. The patient scarcely regarded the pain of the scarification, 
and in a few hours she remarked, that she had never before obtained such relief. A 
suppository of opium was subsequently used. Four or five times af ^wards, this 
method of depletion was practised, and with increasing success. A bland and nu- 
tritious diet and bitter ale were prescribed ; iron in several forma was exhibited, and 

after a lapse of several months, 1 was informed that the health of Mrs. 

so greatly restored as not to require any further medical treatment or care. 



was 



Case 41. 

IRRITABLE UTERUS— TREATED BY THE APPLICATION OF LEECHES TO THE OS UTERI. 

April 20th, 1841. Miss , set. 32, a patient of Mr. Harris, of Fenchurch 

Street, has constantly suffered for more than a year from the following symptoms :— 
Central pains extending from the lowest part of the back and loins, round to the puDis 
in front, and deep down behind the mons veneris, and affecting the urethra and rec- 
tum Occasionally, the suffering is seated in the groins, the anterior and posterior 
parts of the thiahs, often reaching even to the toes. These pains are always aggra- 
vated by exertion, by going up and down stairs, or by mental emotion, but especially 
by any error of diet. Indigestible food, inducing dyspepsia, is sure to bring on an 
exacerbation. Her general health is impaired ; the appetite is capricious, the bowels 
constipated, and never acted upon without an increase of the local uneasiness ; the 
skin is unhealthily dry, and chloroiic ; the pulse quick and irritable, and she is much 
thinner. Has been for many months confined almost entirely to the recumbent pos- 

° On examination, the uterus was found slightly prolapsed, and fts cervix was indu- 
rated, enlarged, and exquisitely painful on touch. The vagina was healthy : examina- 
tion by the rectum proved, that the body of the womb was larger, heavier, and more 
tender than natural. Laughing, defecation, and sometimes even the slight ettort ne- 
cessary to evacuate the bladder, would increase the suffering for many hours, fche 
sleeps badly, is every now and then hysterical, and has some leucorrhcea. 1 he urine 
is scanty, high-coloured, and deposits largely. The approach of menstruation is 
always dreaded as being the certain forerunner of several days' constant suttenng. 
Headache is frequent, and seriously augments her catalogue of ills. 

Eight or ten leeches were ordered to be applied by the speculum tube twice a- 
week, and the horizontal position was strictly enjoined. Mild chalybeates, with 
narcotics, cordial aperients, and nutritive diet, and bitter ale, comprised the whole ol 
the remedial plan. The annexed form of tonic and aperient may often be exhibited 
in these cases with marked benefit: — 

R. Ferri Tartrat. Ammon. 5j. vel 3iss. Syr. Papav. Alb. 3"iv. vel 
Morphise Acetat.gr. j.velij. Tinct. Card.C.o'iv. Aquae purse Bjvij. 
M. ft. Mist. 
One to two tablespoonfuls to be taken twice, thrice, or four times daily. 



IRRITABLE UTERUS, OR HYSTERALGIA. 187 

B. PuIy. Rhei Magnes. Carb. Conf. Aromatic, au Jss. Aquae Pulegii, 
Anethi, Cinnamomi, vel Menthae Piperitidis, 5 xv j* M. ft. Haust. 
aperiens. 
To be taken either on going to bed at night, or early in the morning, once 
or twice a-week. 

On my second visit several weeks subsequently, a satisfactory improvement had 
occurred. Mr. Harris had varied the remedies as occasion required, but leeching had 
been perseverincrly practised, and the catamenial period had been passed over with 
less suffering. The cervix was lessened., and by no means so tender, and the patient's 
hopes were evidently revived. 

It was agreed that there should be no alteration of the plan, and without troubling 
the reader with circumstantial detail, 1 may at once say, that in July she was so much 
improved as to render it further desirable to send her by steamboat to the sea-coast. 
My last inquiries about her were very satisfactorily answered. 

I could add many cases similarly treated, but their narration would 
unnecessarily amplify the size of the work. It will be sufficient to re- 
mark, that uterine enlargement and congestion are not always present, 
and where the disease is evidently and solely neuralgic, the uterus and 
its cervix, although exquisitely tender, being small and shrivelled, rather 
than large and indurated, no advantage can be derived from leeching 
or scarification. In such forms, decided change of air, a sea voyage, 
and a course of chalybeate waters, the Marienbad or Carlsbad, or the 
waters of Harrowgate, are often of great service. It may, too, be men- 
tioned, that this, the real neuralgic form of the malady, is, like dysme- 
norrhoea, often, although not invariably, cured by marriage. 



PAST II. 



OF THE ORGANIC DISEASES OF THE INTERNAL AND 
EXTERNAL FEMALE GENITALS. 



CHAPTER I. 

GENERAL REMARKS ON THE HISTORY AND SYMPTOMS, DIAGNOSIS, 
PATHOLOGY, AND PROGNOSIS OF THE ORGANIC DISEASES OF THE 
UTERINE SYSTEM. 

An organic, unlike a functional disease, is one in which the deviations 
from healthy action are indicated by symptoms during life, and by ap- 
pearances after death, which are always the result of some, and often of 
very conspicuous structural lesion. Cancer, scrofula, and the deposits 
of chronic inflammation, may be adduced as examples. They are less 
complicated and perplexing than the functional maladies; their locality 
is usually more easily discovered, and their extent is generally defined 
without much difficulty. The precise pathology, however, of an or- 
ganic enlargement, whether it be an excess of nutrition, merely increas- 
ing the bulk, or whether the greater size and altered texture be the 
product of malignant change in the viscus, are questions far more dif- 
ficult to solve, and about which the ablest observers, at least for a time, 
often differ. It is also true that the resemblance between comparatively 
inert and malignant organic lesions, is frequently so striking as to render 
the distinction exceedingly perplexing. Hence the diagnosis of such 
lesions where it is practicable, is a matter of great moment. Again, 
we can rarely cure these morbid enlargements and alterations, but 
modern pathology has clearly illustrated many of them, so that we 
may at least avoid an indiscriminate and injurious treatment, however 
little we can effect through the medium of the absorbents for their entire 
removal. 

Still we are occasionally justified in stating, that formidable as may 
be the bulk of some of these growths, rest, self-denial, and dietetic 
management, may and frequently does so far preserve the general 
health, as to permit life to be protracted with tolerable comfort, up to 
and even beyond the usual period. But there are often considerable 



ORGANIC DISEASES OF THE UTERINE SYSTEM. 189 

perplexities in the pathology, treatment, and prognosis; especially, for 
example, where organic diseases of the uterus coexist with pregnancy; 
and where, embarrassing as is the diagnosis, the safety of the patient 
mainly depends on its accuracy. I know, practically, that it is some- 
times almost impossible, with every aid, to arrive at certainty respect- 
ing the precise character of complicated diseases of the womb ; but I 
also know, that they are often overlooked or misunderstood, from the 
want of a sufficiently early and careful investigation. Nor is this de- 
lay to be altogether ascribed to the practitioner: there is, amongst 
delicate females, a natural, although an unsafe repugnance to the early 
and necessary examination; and the concealed situation of the uterus, 
within the pelvic cavity, renders the task, however ably performed, by 
no means a simple one. 

It is scarcely necessary to remark, that to do so successfully, the 
healthy condition, and the healthy varieties of the female generative organs, 
must be understood. It will be in vain to attempt to appreciate morbid 
deviations, if this previous knowledge be not possessed. The reader 
must, therefore, excuse some description of the anatomy of the parts 
and of the normal peculiarities of structure occasionally met with. 

There are several methods of inquiry ; but they are not all equally 
efficient. From two sources, important facts may always be obtain- 
ed ; and from two instrumental methods of examination, and from the 
discharges, knowledge, illustrative and confirmatory of the true pa- 
thology of these affections, may generally be elicited. 

THE HISTORY OF THE SYMPTOMS, and 
THE EXAMINATION BY TOUCH, 

afford, in every instance of organic uterine disease, certain and indis- 
pensable information: whilst 

THE SPECULUM, 

the stethoscope, and 

THE DISCHARGES, 

will often assist, and may occasionally lead to an incontrovertible opin- 
ion. At the conclusion of the chapter, some remarks will be made on 
the pathology of these structural lesions. 

THE HISTORY OF THE SYMPTOMS. 

It is hardly requisite, to enter minutely into all the particulars of a 
suspected case of organic disease: and yet, without the facts which 
the previous history alone can furnish, we shall often remain ignorant 
of the morbid actions of the general system. I forbear more than an 
allusion to the influence of temperament or diathesis.* A strumous habit 
is frequently associated with organic glandular disease ; while a high 
standard of mind, and exquisite nervous sensibility, apart from struma, 
are more commonly connected with hysteria, and the perplexing varie- 
ties of irritation, than with structural change. None of us can forget 
how often, where pain has indicated inflammation, the remedy which 
procured relief clearly proved that irritation was its cause. Nothing 

* It is perhaps worthy of notice, that in thirty -three cases of Carcinoma Uteri oc- 
curring among my out-patients at Guy's, twenty-three of the women were of dark 
complexion. 
13 



190 ORGANIC DISEASES OF THE UTERINE SYSTEM. 

can excuse a disregard of symptoms, supposed to depend on organic 
lesion Every such instance must be a distinct object of inquiry ; and 
every Symptom deserves, if it be possible, to be pathologically traced 
to its true origin. I may illustrate the necessity of such a procedure, 
by a case which has frequently occurred to me. A patient complains 
of difficulty and shortness of breathing, pain in the hypogastric re- 
gion, and general abdominal enlargement. If she have attained fifty 
years of a^e, if there be a tolerably distinct increase of bulk in the 
site of the°uterus, and if there be obstructed action of the large in- 
testine and urinary bladder, a hasty and imperfect inquiry has often 
determined that uterine, or other tumour of a structural kind, was the 
cause of these sufferings. An unfavourable prognosis has been pro- 
nounced, and a merely palliative treatment has been adopted. Let the 
history of these symptoms be carefully inquired into, and it is far 
from improbable that the indications, throughout the whole course of 
the case, may not have pointed to organic change. There may have 
been constant indigestion, torpor of bowels, and general inactivity 
of system. The result is seen in acute and spasmodic pain; in fre- 
quent flatulent distention of the bowels; in a hard enlargement of the 
lower belly; arid in a general and unhealthy deposition of adipose mat- 
ter over the whole of the abdomen;— still, without structural uterine 

disease. 

But it is necessary to be more precise ;— and I shall direct attention, 
first of all, to some important facts, illustrative of the kind of pain, its 
period of attack, and its duration. In diseases of the uterus, it is im- 
possible, as in those of many other viscera, to recognise particular 
affections by characteristic pains. The uterus is but sparingly sup- 
plied with nerves of sensation ; its greatest nervous influence being 
derived from the sympathetic, the nerve of organic life, through the 
medium of the hypogastric plexus ; — a distribution practically illus- 
trated by the indications of organic affection. Thus, it not unfrequently 
happens, that the little acute suffering attendant on the earlier and even 
more advanced stages of these structural changes creates a false and 
pernicious security, leading the patient to postpone the necessary ex- 
amination ; and not to seek advice till the bulk of the growth is pro- 
ducing mechanical inconveniences, so serious and confirmed, as to 
preclude the possibility of more than partial and temporary relief. 
Contrast what has now been stated, with what occurs in functional af- 
fections of this organ, and the assistance to a correct distinction is still 
greater ; here the pain is immediate and severe, and the implication, 
through the medium of the sympathetic nerve, of the other abdominal 
viscera, and oftentimes of the brain, occasions so much suffering as to 
demand prompt and efficient treatment. Thus in chronic structural 
disease of the uterus, there is seldom acute, early, or continued pain; 
while in functional disorders, such as irritation, and in inflammation, 
these conditions are invariably present. 

The pains dependent on increased bulk and displacement of the uterus 
are common to many, and diversified affections of the viscus. Sup- 
posing the uterus to have attained equal size, the painful indications 
will be nearly the same, whether the increased volume is produced by 
chronic vascular congestion, by hard fibrous or even calcareous tu- 



ORGANIC DISEASES OF THE UTERINE SYSTEM. 191 

mours, by polypi, or by accumulations of fluid or air within its cavity. 
Ihe suffering here is the consequence of mechanical pressure, and en- 
croachment on neighbouring parts: and in all these cases, the patient 
will complain of dragging pain in the loins, extending occasionally to 
the anus and pennaeum; of weight and fulness in the hypogastrium 
^constipation of the bowels, if the uterus press on the rectum ; or 
of difficult micturition, if it incline forwards and rest on the urethra or 
neck of the bladder. Again, should the uterus become largely dis- 
tended at its sides, it may press on the obturator nerve ; such pressure 
being indicated by screwing pains at the hips or inside of the thighs, 
or in any part of the course of the abductor muscles. A further in- 
crease of bulk may involve the sciatic; or, if above the pelvic brim, 
the anterior crural nerve ;— points easily ascertained, by the pain being 
referred to the course of these nerves. But pains of a like kind are 
common in some of the displacements of the uterus, especially in pro- 
lapsus and procidentia. Nor are the sufferings occasionally attendant 
on the growth of the gravid womb very dissimilar. The distinction 
is not however, difficult: the recumbent posture favours the return of 
a prolapsed, procident, or ante-verted uterus, and consequently sus- 
pends the pain ; while the permanency of the morbid distentions and 
growths allows of scarcely any relief to the mechanical pressure, which, 
although slightly modified by an alteration of posture, is not removed. 
A variety of indications will insure a correct opinion, in most cases 
of pregnancy. One, perhaps, deserves especial notice; viz., that the 
pam is rarely felt, in this state, during the gradual and natural disten- 
tion of the womb, but during its premature or healthy contractions. 

The duration of the pain and other morbid changes dependent upon 
it, deserve consideration. Whatever might be the symptoms, organic 
alteration would scarcely be suspected, except from the examples of 
some very rapid and rare malignant affections, where the suffering and 
other morbid symptoms had existed only for a few weeks. Such mala- 
dies, unlike inflammations and fevers, require months at least, and often 
years, for their full establishment. Eventually, and principally by me- 
chanical pressure, the functions of other and neighbouring viscera are 
interrupted ; disorganising changes in their structure afterwards oc- 
curring, which ultimately affect the organic growths themselves. Nor, 
without the examination by touch, or the speculum, can we safely pro- 
nounce that there is no ulceration of the uterus, because there is no 
lancinating pain. It is true that suffering of this kind generally ac- 
companies ulceration; but numerous instances in the wards, and 
amongst the out-patients, attest that it is by no means an invariable 
concomitant. I have, every year, patients in the last stages of these 
diseases who still do not require opiates, so slight and transient is the 
pain caused by the ulceration. 

Emaciation is regarded as an almost unequivocal sign of structural 
lesion ; and in the truly malignant diseases, it is seldom absent : but in 
hard tumours of the uterus, even of great size, there is often no ema- 
ciation, till the period when ulceration has occurred in neighbouring 
organs or tissues, and when the tumour itself is beginning to soften and 
break down. Where, however, the tumour is growing rapidly, or 



!92 ORGANIC DISEASES OF THE UTERINE SYSTEM. 

where it is producing irritation by mechanical pressure, digestion is 
soon impaired, there is little or no appetite, and flesh is sensibly and 

Quickly lost. . i 

I have now enumerated the principal circumstances properly in- 
cluded in the history of a structural disease of the uterus : and it may 
further be remarked, that any event affecting the vital properties or 
functions, dependent on the real or supposed organic malady, is pro- 
perly comprised in this section : the deviations in the anatomical or 
physical properties of any viscus being the objects of the examination 
by touch or by the speculum, by the stethoscope, and by the dis- 
charges There will exist other symptoms of less importance, but 
still deserving of some remark and enumeration. A history ot any 
siven case might not be very incomplete without these lesser details ; 
but the diagnostic record of any structural disease must be essentially 
imperfect, which does not direct the attention of the reader to the age, 
the temperament, the kind of pain, the duration of the malady, the 
effect upon the general health, more especially as to emaciation, and 
the degree of obstruction or difficulty in the functions of the diaphragm, 
intestines, or urinary bladder. I shall now pass on to the 

EXAMINATION BY TOUCH, 

our most valuable means of diagnosis, especially when aided by the 
speculum, and on some rare occasions by the stethoscope. Here pre- 
liminary anatomical knowledge is essential. The practitioner, to 
whom the healthy structure of the uterus and its appendages is un- 
known, will try in vain to appreciate the nature and extent of its mor- 
bid deviations ; he may examine, but he will not know for what he 
seeks. The pathology of organic disease of the uterus rests on ana- 
tomy : a correct diagnosis must, therefore, mainly depend on correct 

anatomical knowledge. . , 

The anatomy of the uterus, for the purposes of diagnosis, may be 

arranged in two divisions. . . 

In the first, may be considered its structure ; and in the second di- 
vision, its size, relative position, or locality. 

The structure of the uterus is not difficult to be understood. Ex- 
ternally, it is invested by a serous, while within it is lined by a mucous 
membrane : the covering externally is the peritoneum ; while the in- 
ternal lining is a prolongation of the mucous surface of the pudendum 
and vagina. Between these lies the proper substance of the uterus, or 
its parenchyma ; made up of its peculiar muscular fibre, its arteries, 
veins, lymphatics, nerves, and intervening cellular tissue. It is not ne- 
cessary to mention the sources whence its supply of blood and nervous 
influence are derived, because these are points generally known; but 
I cannot forbear observing, that this simple anatomical arrangement is 
the key to the study of uterine affections. Each of these parts may 
be separately the seat of disease: the peritoneum may be inflamed, 
without the mucous membrane or the parenchyma ; and will present 
symptoms and changes, strikingly unlike those which shall be produced 
by inflammation either of the mucous membrane or the proper struc- 



ORGANIC DISEASES OF THE UTERINE SYSTEM. 193 

ture of the organ. It will not, however, be discovered, that the phe- 
nomena accompanying peritoneal inflammation of the uterus differ 
from those attendant on inflamed peritoneum of other parts, or on in- 
flamed pleura or arachnoid ; though the situation of these latter mem- 
branes is widely distant ; and the functions of the viscera, of which 
they are parts, widely different from that of the uterus. The same re- 
mark is true of the inflammation of the uterine mucous membrane, the 
progress and results of which closely resemble the inflammation of 
similar structures in other parts of the body. Nor is the parenchyma 
of the uterus excepted from this general law. It will be found liable 
to the like morbid structural and malignant alterations as the paren- 
chyma of other organs. 

I need not, however, enlarge, as I must hereafter direct attention 
to certain facts of this kind ; especially to the difference between struc- 
tural change in the walls and body of the uterus, and similar disease 
affecting the cervix of the organ. 

The second division of the anatomy of the uterus comprises its size, 
and relative position or locality. 

A minute description of the bulk, weight, and situation of the womb, 
in reference to the other viscera of the pelvis, is not required ; but it 
is necessary to state a few leading particulars, all of them bearing on 
diagnosis. The form of the uterus is that of a flattened pear ; mea- 
suring from fundus to os, after the full establishment of puberty, and 
prior to childbearing, a little more than two inches. After several 
pregnancies, this dimension will reach nearly three inches. 

The weight of the adult virgin uterus, without its appendages, is 
not an ounce ; after several children, it is seldom less than one and a 
half, or two ounces. 

The breadth of the fundus in the adult virgin uterus, is about an 
inch and a half; and a little more when that organ has been impreg- 
nated. 

It is placed obliquely in the pelvis ; having the bladder in front, the 
rectum behind, and the convolutions of the ileum above : partially sup- 
ported by its ligaments, but most effectively by the vagina. The shal- 
lowness of the pelvis before, and its greater depth laterally and towards 
the sacrum, are points of great moment in examination. The fundus 
of the uterus rises as high as the superior margin of the pubes, lying 
forwards ; and the cervix a^d os, stretching posteriorly, or nearly in 
contact with the middle or lower third of the sacrum. 

There are two principal methods of examination by the finger : the 
first externally, above the pubes ; and the second, by the vagina. 

Examination by the rectum will often clear up a doubtful point ; — the 
posterior and more prominent surface of the uterus resting on the an- 
terior part of the bowel. The principal facts elicited by the external 
examination are, the bulk and form of the organ ; its induration, or 
softness ; its precise situation ; the effects produced by pressure, such 
as pain in the part or at a distance, syncope, fyc. ; and its fixedness 
or movability. 

When we attempt to measure the anteroposterior diameter of the 
pelvic brim, in reference to labour, it is a most favourable circum- 



194 ORGANIC DISEASES OF THE UTERINE SYSTEM. 

stance that the finger, in a common examination, cannot reach the 
promontory of the sacrum ; as it is thereby proved, that in this the 
principal diameter, there is plenty of room. A similar remark is 
equally true of the uterus : if in this external examination by the hand, 
there is no tumour felt above the brim, or more laterally, it is at least 
a proof that the viscus does not greatly exceed its normal dimensions. 
The patient, to afford us every advantage, must be placed in the re- 
cumbent posture, on her back, and of course without stays ; the shoul- 
ders elevated, and the lower extremities flexed upon the trunk : thus, 
relaxation of the abdominal muscles is fully secured. The examina- 
tion will be more easily conducted, if the fat covering the abdomen 
be gently and gradually kneaded or pushed from the hypogastric 
region. The bladder and rectum ought to be nearly empty, and the 
intestines must not be distended with air. Prolonged examination is 
generally unnecessary ; and, without arbitrarily limiting the time, 
such an inquiry ought never, as a general rule, to exceed a few 
minutes. 

As we presume that there is increased abdominal bulk, our object 
is to ascertain its precise nature. There may be pregnancy, — a hard 
or scirrhous tumour distending the womb, without pregnancy ; preg- 
nancy, complicated with one or more tumours of the uterus or ovary ; 
or pregnancy coexisting with ovarian dropsy. There may, too, be 
accumulations of air or water in the cavity of the viscus ; although 
tympanitis and dropsy of the womb, to any extent, are, in my experi- 
ence, exceedingly rare. Of course, a minute and accurate know- 
ledge of the abdominal region in health, and of the feeling then 
imparted to the finger by the various viscera, will aid much in the 
exploration. When there is disease, the difference is truly great be- 
tween the tact and observation of different practitioners, in visceral 
affections of this region of the body. 

If the growth depend on pregnancy, not to mention the early signs, 
the situation, shape, and hardness or softness of the tumour, will throw 
much light upon the question. The situation of the tumour, presuming 
it to be a pregnant uterus, will vary with the different periods of ges- s 
tation. At the third month, the fundus of the organ will be felt just 
above the crest of the pubes ; while at the sixth month, and after- 
wards, it will reach and ascend for an inch or two above the um- 
bilicus. Thus, if the examination be made about the sixth or seventh 
month, provided there be none of the complications already alluded 
to, the oval form of the distending body ; the larger extremity of the 
oval lying above and forwards, at or a little way above the level of 
the navel ; its freedom from tenderness on pressure ; the firmness felt 
in the tumour, so much greater and more defined than in any part of 
the abdomen, excepting the region of the liver, owing to the intestines 
occupying the spaces above and at its sides ; are all of them circum- 
stances confirmatory of the fact of pregnancy. Be it remembered, too, 
that these changes may all be satisfactorily ascertained, if the cover- 
ings of the abdomen are not unusually fat. And even where we meet 
with this great obstruction, the kneading process will avail much : at 
all events, the hardness or softness of the growth may be noticed. 



ORGANIC DISEASES OF THE UTERINE SYSTEM. 195 

Hardness, it is true, belongs to scirrhous tumours of the uterus ; but 
they are usually lobulated, and sometimes almost stony; while the in- 
duration of pregnancy is of even surface, and only of moderate firm- 
ness ; excepting when the womb is in action, when the hardness re- 
sembles that of marble. 

I need not pursue this inquiry further. If pregnancy be strongly 
suspected, the stethoscope will be used ; and if the pulsations of the 
fcetal heart be heard, all doubt is at an end. 

If the enlargement of the womb result from scirrhus even though it 
be considerable, its diagnosis, where there is no pregnancy, is not dif- 
ficult. The irregular and uneven surface of the growth, the separate 
knobs of induration, the number of the tumours where there are more 
than one, the long time generally occupied in their development, and 
the symptoms of continued mechanical pressure on neighbouring 
organs, prevent an erroneous conclusion. It may then be granted, 
that the external examination will frequently lead us to a correct and 
decided opinion, in those examples of doubtful enlargement produced 
solely by pregnancy, or solely by one or more hard tumours of the 
womb. 

But wili it suffice, where tumours of the uterus or ovary, or dropsy of 
this latter organ, or growths from the broad ligament or other parts of 
the pelvis, are coexisting with pregnancy ? 

It may suffice even here, if these morbid conditions were known to 
exist prior to the pregnancy ; and if this latter state has occurred in the 
usual manner, and is attended by the common and natural signs. Here 
there would be dangerous complication, but there would be no doubt. 
It sometimes happens, however, that women marry late ; or, having 
been married early, conceive after many years of barrenness ; or, 
having borne children rapidly at first, leave off doing so, till they have 
arrived at that period when the power of reproduction might be sup- 
posed to have ceased. Pregnancy in these latter circumstances is often 
doubted. Structural disease generally occurs at this age : and if the 
symptoms of the supposed pregnancy are incomplete and irregular, 
there is fair ground for hesitation. The bulk of the abdomen may per- 
haps be disproportionate to the presumed period of impregnation ; 
there may be a painful hardness in one part, and a want of proper size 
in another part of the abdomen ; the catamenial suppression may not 
have been complete ; the vagina] discharges may have been rather 
profuse and unhealthy ; and the movements of the child may have been 
only partially and feebly felt. All these peculiarities may depend on 
structural disease, coexisting with pregnancy ; and several cases of 
mine, in a Paper in the First Volume of Guy's Hospital Reports " On 
the propriety of inducing premature labour in pregnancy complicated 
with tumour" prove these statements to be entirely true. In these 
instances, the opinion was most difficult : the history of the symptoms, 
and the external and internal examinations, scarcely sufficed for a 
positive diagnosis. In one of them, the stethoscope detected the beat 
of the fcetal heart ; while in another, some doubt existed, till labour 
pains really occurred : nor was it possible to remove this doubt, as 
there were two very large tumours developed in the walls of the 



196 ORGANIC DISEASES OF THE UTERINE SYSTEM. 

uterus, in front and laterally ; and the placenta was completely over 

the os. 

It is clear that the external examination alone, in such complica- 
tions, cannot lead to a positive conclusion of what the case really is. 
The shape, the consistence, whether solid or fluid, and the extent of 
the abdominal enlargement, may be thus ascertained. The pulsations 
of the foetal heart, if the child be not feeble or dead, even where 
there is growth in the walls of the womb, may sometimes be heard 
through the stethoscope ; although it will more frequently happen that 
this invaluable instrument will be used in vain, I forbear, for rea- 
sons hereafter explained, to allude to the placental souffle. All 
this may have been accomplished, and yet we are far from cer- 
tainty. 

The internal examination by the vagina, and, if necessary, by the 
rectum, must be employed. In cases merely of doubtful pregnancy, 
where there is no suspicion of uterine disease, a cautious practitioner 
would not commit himself without this internal examination, except he 
had heard the beat of the foetal heart, or had felt the foetal movements. 
In those examples, therefore, of abdominal or pelvic enlargement, 
where pregnancy is thought to be complicated with disease, such in- 
quiry is indispensable : and occasionally, with all the information it 
affords, we shall . hesitate to pronounce a positive opinion. It is far 
easier, by this vaginal inquiry, aided by the speculum, to recognise, 
not only the existence, but even the precise nature and extent of ute- 
rine and vaginal disease, than it is to determine whether pregnancy 
really exists in connexion with organic change, thus producing the 
augmented bulk. There are few things so difficult as to form a cor- 
rect diagnosis in these cases. In my opinion, however, the determi- 
nation of the pregnancy is the most serious question : for if there be 
no foetus in utero, a palliative treatment will be proper ; whereas, if 
the patient be pregnant, her safety mainly and almost solely depends 
on the induction of premature labour. 

The solving of this question requires that we ascertain the condition 
of the neck and mouth of the womb, the size and condition of its body, 
and the nature of the uterine contents, especially as to motion ; if these 
various parts of the uterus are changed, as in simple and natural preg- 
nancy, the opinion will be certain, and we shall proceed with confi- 
dence. The patient must be placed on her left side, the usual obste- 
tric position ; and the labia and nymphse being carefully separated, the 
forefinger of the right hand will commonly reach and touch the parts 
satisfactorily. It must, however, be remembered, that the sensitive 
part of this finger can only examine with nicety that portion of the 
neck and os lying opposite to it : to examine the whole circumference 
of the neck, the index finger of the left hand must also be used ; and 
then it is scarcely possible that any morbid spot, or induration, can 
escape detection. As in the operation of lithotomy, a deep perinaeum 
increases the difficulty ; so in the internal examination, an unusually 
long vagina, a broad perinaBum, and large and fat labia, present 
obstacles to the investigation by a single finger. In such patient, 
two fingers, or perhaps the whole hand, must be used ; having been 



ORGANIC DISEASES OF THE UTERINE SYSTEM. 197 

previously lubricated by oil, rather than by any unctuous substance. 
If the neck be supple, broad, soft without tenderness, and if the os be 
closely sealed, so far the evidence is in favour of pregnancy. Doubts 
may arise here, because a polypus may distend the cavity, and lead to 
development of the neck, but the os would hardly be sealed ; the neck 
itself may be the seat of chronic inflammation, or of hard tumour, 
generally diffused or confined to one spot ; those may be puckered, 
fissured, or indurated by cicatrices, thus obscuring the indications : but 
even here, tact will scarcely fail to appreciate in what degree the in- 
dications are to be relied on ; the practitioner never forgetting, that all 
these morbid conditions may exist in the neck of a pregnant uterus. 
A sealed os would, in a case of such perplexity, avail much : tumours 
growing from the neck, or os, would perplex, but would not greatly 
interfere with the opinion. 

The second part of this inquiry refers to the body of the uterus. 
And if the enlargement be globular, arising equally from every part of 
the circumference of the neck, expanding upwards after the manner 
of a balloon, affording an elastic resistance to pressure, such indica- 
tions most probably result from pregnancy. Enlargement, it is true, 
may arise from hypertrophy, polypi, hydatids, and solid growths of 
various kinds ; but here the resistance to the pressure of the finger 
would be different; there would be little or no elasticity, excepting 
where there are hydatids ; for hydrometra or physometra need not be 
included ; and there would be a solidity about the uterine mass, which 
could scarcely be mistaken for pregnancy. 

The third fact to be discovered is, the nature of the uterine contents ; 
and especially whether they possess the power of motion. The stetho- 
scope is not always available, even where the child is living ; and where 
it is dead, it can afford no help. I have already alluded to the differ- 
ent kind of resistance to the pressure of the finger, on the lower part 
of the body of the Uterus. Where there is fluid in the cavity of the 
womb, the fluctuation, and perhaps the sound, will afford tolerable evi- 
dence: and if the palm of the left hand be placed over the hypogastric 
region, when impulse is given to the fluid by the finger in the vagina, 
there will not be much doubt of its locality. If there be a foetus in 
this fluid, the same impulse will cause it to rise; and having floated for 
an instant, it will again subside on the finger. This is termed " ballo- 
tement," or balancing the foetus, and can be practised with equal fa- 
cility, whether it be living or dead. 

Examination by the rectum will afford a correct idea of the degree 
of uterine enlargement, and of the pressure which it exerts posteriorly, 
and perhaps laterally. It may, too, confirm the impression of the so- 
lidity or fluidity of the uterine contents. The morbid peculiarities of 
the neck, already mentioned, may slightly interfere with the exami- 
nation of the body ; but not so seriously as to prevent our distinguish- 
ing whether the contents of the viscus are hard, heavy, and incom- 
pressible, or fluctuating and elastic. 

The placenta being entirely or even partially over the mouth of the 
womb, hypertrophy of the lower part of the organ, or one or two tu- 
mours being situated in its front or sides, will, of course, prevent the 



198 ORGANIC DISEASES OF THE UTERINE SYSTEM. 

certain conclusion which might otherwise be drawn : but we still have 
the history of the case, the previous pregnancies, if there have been 
any, the external abdominal enlargement, the examination by touch, 
and the stethoscope. This, then, is the inference fairly deducible — 
that although there are cases , where the able employment of all our diag- 
nostic means fails to make us certain of the existence or non- existence of 
pregnancy, yet that such examples are very few, compared with the number 
in which such means, used with tact, will conduct us to a positive and cor- 
rect opinion. 

If the indications afforded by the vaginal examination, in doubtful 
and complicated pregnancy, approach thus near to certainty, the 
touch, in most of the diseases of the cervix and os, aided by the speculum, 
must lead to a positive and correct opinion. Often, however, the 
former mode will suffice ; and it ought, in every instance, to be first 
employed. There is scarcely a case in which the examination 
by touch may not be used, once at least; while there are not a few 
in which the inspection by the speculum is absolutely injurious to the 
sound, as well as to the unhealthy structures of these organs. By the 
finger, we can correctly ascertain the size and shape, the consistence, 
the temperature, and the sensibility of the parts to be examined. Ul- 
ceration, or abrasion, may also be detected by the touch, but not with 
accuracy, as to its nature or extent. 

The cervix is seldom more than an inch in length ; and is attached 
to the womb, like a firm, solid nipple. It is lined, both externally and 
within, by mucous membrane. It differs sensibly from the body of the 
uterus, being glandular, and, of course, more compact and condensed 
in its structure ; and, so far as I have examined it, without a trace of 
muscular tissue : it is the channel of communication between the va- 
gina and uterine cavity. Every solid body, whether it be the child, a 
polypus, a hard tumour, or hydatids, can only find egress through the 
distended and yielding, or diseased cervix. All the secretions of the 
uterine cavity, be they healthy, or offensive and irritating, must pass 
over its surface : added to which, it is frequently exposed to contusion 
and inflammation, from sexual intercourse, and from the use of ob- 
stetric and other instruments. If it be true, that a part is liable to or- 
ganic change, in proportion to the excess or even the frequency of its 
action, we need not wonder that the cervix is so often the seat of 
chronic inflammation and of structural disease. 

Varieties in the form and size, and to a certain extent in the structure 
of this part, are not uncommon; and here it is, that precise anatomical 
knowledge is so valuable. Often have I been told that the neck was 
organically diseased, when in one or other of its usual conditions, there 
was only a healthy peculiarity. A cervix, smaller or larger than the 
natural one, is often met with ; and if there be nothing morbid in its 
structure or function, it is undeserving of pathological attention. The 
extremes of size may exist in the healthiest women. An elongated 
cervix is not so uncommon as I formerly supposed. Naturally the 
cervix hangs in the upper part of the vagina, not touching its parietes ; 
but if it be of abnormal length, it will, of course, touch the vaginal 
surface; and, if very long, may produce irritation and leucorrhcea. 



ORGANIC DISEASES OF THE UTERINE SYSTEM. 199 

In estimating pregnancy, and its period, by the development of this 
part, the possibility of a naturally elongated neck must not be forgotten, 
as such a variety is one of the exceptions to this indication. The 
apex, or inferior extremity of the neck, is pierced by an aperture, 
called the os, of an oval form, and with its long diameter transversely. 
At puberty, and prior to parturition, it is not longer than a quarter of 
an inch ; while in women who have had several or many children, its 
length is nearly double. The os is naturally always open; and where 
the neck has been frequently dilated by the passage of a child, its edges 
are widely separated, and so gaping, that they will easily admit the tip 
of the forefinger. In touching these parts, it must be recollected, that 
the anterior lip is the largest, owing to the chink, or os, not being ex- 
actly in the middle of the cervix : it is placed more behind than before 
— a fact easily proved by examination. I have never known the os 
to extend from before, backwards ; but I have several times, both in 
the married and unmarried, and even in women who have borne chil- 
dren, found the cervix remarkably small and compact, perforated by 
a most diminutive circular aperture, instead of the usual os. Very 
rarely, there is only the rudiment of a cervix, there being no glandular 
appendage. The aperture, in this case, is formed in the simple struc- 
ture of the body of the womb ; and slight inflammation may be suffi- 
cient for its closure or obliteration. Such an example has been de- 
tailed in the Guy's Hospital Reports;* and Dr. A. T. Thompson's 
case of dropsy of the womb supplies additional testimony to its occa- 
sional though rare occurrence. 

A large uterus, especially at its lower part, a large and soft cervix, a 
patulous os, fissured, indurated, and cicatrized, may all exist without 
organic, and especially without active organic disease. Prior to, during, 
and even soon after the catamenial flow, the body, and particularly 
the neck of the uterus, is larger, and more supple than natural ; and 
imparts to the finger a similar sensation to that communicated in the 
early months of gestation. Frequent sexual intercourse will also in- 
duce this state of parts. During natural and healthy menstruation, 
the orifice of the neck is very dilatable, and easily allows the passage 
of the finger: this will but rarely occur at other times, independently 
of disease ; and the opinion will be unfavourable, if the finger, on pass- 
ing into the canal of the cervix, shall touch a puckered, coarse, and 
rough membrane. 

Induration and cicatrization, in slight degree, may result from 
lacerations during labour, and from the inflammation attendant on 
their union. ^ In old women, it is especially important to remember, 
that the cervix naturally diminishes in size, and the contraction of its 
structure is almost invariably associated with considerable induration ; 
but still, without disease. It has often occurred to me to verify this 
statement. I might enlarge here ; but the structural varieties already 
enumerated, are perhaps sufficient to guard a careful examiner against 
error. Deviations more marked and positive than these, attended by- 
pain and discharge, justify a decidedly unfavourable opinion. 

* Vol. ii., p. 258. 



200 ORGANIC DISEASES OF THE UTERINE SYSTEM. 

It will not be difficult to appreciate morbid change in the consis- 
tence of the neck ; for although the cervix possesses the firmness of a 
gland, this may, by a practised examiner, be easily distinguished from 
the induration, with tenderness, of chronic inflammation; and still 
more easily from the almost stony or marble hardness of a scirrhous 

tumour. . , 

Ao-ain, the unnatural softness and moisture of this portion of the womb, 
is probably indicative of slightly altered organization, of slow progress 
and less dangerous character, where it is the result of present or former 
hemorrhages and leucorrhoea than where it succeeds diffused or isola- 
ted induration. In the former case, it may continue for years, and per- 
haps to the end of life, without ulceration ; while in the latter, it is often 
the forerunner of that breaking down and malignant degeneration so fre- 
quently seen in these structural maladies of the cervix. I cannot forbear 
to caution the practitioner against a hasty and alarming prognosis, where 
unhealthy softness is connectedwith losses of blood and irregular catamemal 
discharges. Such a condition is curable; and occasionally, where 
little has been done, it has continued for years, perhaps till the final 
departure of the catamenia ; and the cervix has then acquired its usual 
firmness. There are other states, not so easily defined, and which 
can only be recognised by a practitioner frequently in the habit of 
touching these parts : — on these I cannot dwell. 

The sensibility and temperature of the os and cervix are neither of them 
considerable in health ; and as, in a common examination, the mode- 
rate pressure of the finger ought not to produce pain, and as there 
ought not to be sufficient heat to excite notice, a practitioner can 
scarcely err in deriving, from the facts, supplementary information. 
Pain and heat, in high degree, are both present in inflammation of cer- 
vix ; while in the early and more advanced stages of organic disease 
they are often, if not generally, absent. Of course, where the dis- 
ease is softening, and passing through the changes prior to ulceration, 
there will be more or less of heat and pain. 

Abrasion and ulceration may both be detected by the finger, and, in not 
a few instances, sufficiently satisfactorily to supersede the use of the 
speculum. Where the former is known to arise from temporary 
causes, and where the latter is a consequence of the breaking down 
of hard tumours, the delicacy of the patient may be consulted, without 
compromising her safety, by abstaining from the employment of this 
old and valuable instrument. 

EXAMINATION BY THE SPECULUM. 

It does not come within the scope of this work to give the history 
of the speculum. It may suffice to observe, that, by its use, the eye, 
as well as the finger, is made to assist in the diagnosis of organic dis- 
eases of the neck and orifice of the womb : for while the touch enables 
us to recognise structural changes in the bulk, firmness, and sensibility 
of these parts, the sight rectifies and perfects an erroneous or incom- 
plete opinion, by showing the nature and limits of ulceration, excoriation 
or eruption, the appearance of the cervix and vagina in various stages 



ORGANIC DISEASES OF THE UTERINE SYSTEM. 201 

of disease, and the colour and consistence of the accompanying dis- 
charges. 

The best and most easily used speculum is made of tin or pewter, 
with an inner high-polished surface. There need be no division in the 
cylinder, and the complicated screw is not required. I have, for hos- 
pital and private use, a series of these conical tubes, of various sizes : 
and the previous introduction of the finger into the vagina enables me 
to select the right-sized speculum. The length of the tube should be 
from five to seven inches, and it may or may not have a handle : on 
the whole, it is, perhaps, more readily used without one. The strong 
light of the sun is the best for these examinations, but a candle is an 
excellent substitute. 

The rules prescribed for the introduction of obstetric instruments 
into the vagina will serve here. The labia being widely separated, 
the speculum is to be carefully and slowly passed, backwards and 
downwards, towards the point of the coccyx. The principal obstacle 
is at the entrance of the vagina ; for when the resistance of its sphincter 
is once overcome, the speculum will easily traverse the rest of the ca- 
nal. Care must be taken that the transverse portion of mucous mem- 
brane, placed posteriorly, called the fourchette, is not stretched and 
carried forward by the instrument, as great pain and difficulty in the 
introduction will be the result. 

The position of the neck is occasionally changed, being placed more 
forward or posteriorly than natural. To obviate this difficulty, and 
to bring the cervix within the end of the tube, the speculum must be 
elevated or depressed. Sometimes, from spasmodic contraction, in- 
duced by the passing of the cylinder, a fold of the mucous membrane 
of the vagina is forced into the aperture of the speculum, and may be 
mistaken for the cervix : the least movement, however, of the instru- 
ment, will cause the slipping away of the portion thus placed ; and the 
recognition of the neck, which is glandular, smooth, and without rugae, 
and paler than the vagina, is not difficult. 

The whole circumference of a very large cervix cannot be examin- 
ed at once : the position of the speculum requires attention ; and if the 
parts are not morbidly sensitive, the instrument is easily and safely 
turned in the vagina : this caution is important, as very lately I over- 
looked a rather large ulcer on the inferior and posterior surface of the 
neck, from a neglect of it. 

We may, then, by the speculum, accurately ascertain the different 
external morbid conditions of the cervix and its orifice ; and in many- 
instances, where the os is entirely or even partially open, the nature 
and extent of disease affecting the cavity of the neck may be readily 
known. And although the structural changes of the body and walls 
of the uterus do not admit of elucidation by the speculum, still the 
growths of its lining membrane are not entirely beyond the reach of 
its diagnostic agency : for if large, they will descend towards the ori- 
fice of the viscus ; and if ulceration affect the uterine cavity, it is most 
probable that it will eventually reach the neck, and thus be brought 
within the scope of the speculum. 

In health, the cervix uteri is, externally, of pale colour, having the 



202 ORGANIC DISEASES OF THE UTERINE SYSTEM. 

aspect of polished skin ; and it is easily distinguished from the lining 
membrane of the vagina, which, from its different structure and greater 
supply of blood, has a much deeper tint of red. These parts are na- 
turally covered with a thick mucus; a fact of importance, as, if it be 
not removed by lint or a soft brush, abrasions or ulcerations, being 
thus obscured, might be overlooked. 

Valuable as is the speculum, its use has been indiscriminately and 
unnecessarily urged. In slight cases of uterine irritation and leucor- 
rhcea, its employment is prejudicial ; while, in leucorrhceal discharges 
of long standing, and in menorrhagia of months and years' continu- 
ance, its introduction cannot be too strongly recommended : for it 
must never be forgotten, that these maladies rarely exist long, without 
more or less of organic change. If there be a suspicion of structural 
mischief about the lower part of the uterus, there ought to be no de- 
lay, not only in touching, but in seeing the seat of the suspected dis- 
ease. 

There are circumstances which entirely forbid the employment of 
the speculum. In very young and very old persons, its introduction 
is difficult, and sometimes altogether impossible, without laceration. 
The hymen in the young, and the gnat shrinking and contraction of 
the vagina in aged women, present obstacles so serious, that the use of 
the speculum ought to be given up, unless the necessity be extremely 
urgent. 1 have several times found membranous bands stretching 
across the vagina, and contractions of its calibre from cicatrices, 
which would have entirely impeded the passage of the instrument. 
There was lately an out-patient of mine at Guy's, whose vagina was 
so funnel-shaped at its upper part, as to preclude my touching the os or^ 
cervix, except by a probe, introduced through the minute aperture at 
the apex of the funnel by which the catamenia escaped from the uterus. 
Steatomatous tumours occupying the walls of the vagina, ovarian 
growths in the recto-vaginal septum, polypi, deep ulcerations of the va- 
gina or neck of the uterus, large cauliflower excrescences, or bleeding 
fungi, all contra-indicate the use of the speculum. When the neck is 
inflamed, or much congested, or where the vagina is excessively sensi- 
tive, the introduction of the speculum should be deferred, till these vari- 
ous morbid conditions are ameliorated. 

Making every deduction which the enthusiasm of some individuals 
in its favour demands, the speculum must be regarded as a most im- 
portant addition to our diagnostic and curative means. It enables us 
not only to discover and nicely to distinguish the otherwise concealed 
diseases of the inferior or cervical portion of the womb, but, by the 
light which it throws upon the seat of the mischief, it affords great fa- 
cilities in the exact application of remedies. It is much to be wished, 
that the advantages which it is capable of conferring were more early 
and extensively realized. 

THE STETHOSCOPE 

Is solely valuable, as a positive indication, where the beat of the foetal 
heart is heard. It is only, therefore, in those diseases of the womb 



ORGANIC DISEASES OF THE UTERINE SYSTEM. 203 

where pregnancy is suspected, that we require its aid. The " placental 
souffle" may be thoroughly imitated by the pressure of a tumour on 
the iliacs, or any of the large abdominal vessels. In Guy's Hospital 
my attention was once called, by Mr. Oldham, to two of my patients, 
lying in adjoining beds: the one, suffering from a hard tumour of the 
uterus, extending towards the left side; the other, in the seventh month 
of pregnancy, and enduring great pain from a malignant, and as it 
proved in a few weeks, fatal disease of the external genitals. In the 
latter patient, the "placental souffle" was readily detected, over the 
greater part of the upper portion of the uterus, beating synchronously 
with the maternal pulse. In the former, a very distinct " bruit de souf- 
rlet," as loud, and nearly as perfect as in the pregnant patient, was per- 
ceptible. This sign did not embarrass the diagnosis, as the tumour was 
not fixed, and could easily be removed from the iliacs, the "bruit" 
ceasing with its altered position. The sound, in both cases, was nearly 
identical: perhaps the "souffle" of pregnancy was more prolonged, 
and less sharp than the other. 



THE DISCHARGES. 

In the chapter on leucorrhcea, the reader will find some useful infor- 
mation as to the different sources and varying character of uterine and 
vaginal discharges. On the alterations which occur in these, as the 
consequence of excitement, inflammation, and structural change, the 
practitioner must principally rely for the diagnosis, whenever an exa- 
mination is denied. But the knowledge so derived, independently of 
the touch and the speculum, is necessarily restricted and uncertain. It 
is restricted, because there are but few uterine organic diseases, which, 
throughout all their stages, are attended by one discharge only, whether 
it be either mucous or watery, purulent or sanguineous: and it is uncer- 
tain, because several of these may be present at once, variously com- 
bined, as the consequence of an affection, usually attended by only one 
of them; and because diseased conditions of the reproductive organs, 
really differing from each other, as prolapsus, and scirrhous or sub-mu- 
cous tumour, do occasionally, during some part of their progress, give 
rise to each of these different secretions. 

Thus, a white discharge may be equally the sign of a structural dis- 
ease, as of a merely functional leucorrhcea. It cannot, therefore, with 
truth be regarded, as the inseparable and unerring diagnostic of either 
lesion. To distinguish accurately, indeed, between a mucous and puru- 
lent discharge, is often in itself a difficult matter, unless both are placed 
together, and tests applied for each; and even then, supposing the in- 
formation to have been obtained, it is only from an examination by touch 
and the speculum, that we can determine what particular structure is 
the seat of the affection. The prevalent notion that a purulent discharge 
is always yellow, and a mucous discharge always white, is incorrect; as 
the latter may assume every shade of colour between a white and a 
light green. 

Again, as the os externum is the only outlet for the morbid secre- 
tions of the continuous raucous membrane of the vagina, uterus, and 



204 ORGANIC DISEASES OF THE UTERINE SYSTEM. 

Fallopian tubes, and for the glandular apparatus of the cervix, each of 
which parts may be differently affected at the same time, it is obvious 
that an intermixture of several discharges may occur, and be submit- 
ted to our inspection, which must necessarily prevent an accurate 
diagnosis. It is not affirmed, that the discharges attendant on an in- 
flamed cervix or vagina, where, from the intensity of the inflammation 
they may have become acrimonious, of bad odour, purulent, and slightly 
sanguineous, are for a continuance so like the discharges resulting from 
cauliflower excrescence of the os or carcinomatous ulceration of the 
cervix, that a distinction cannot generally be made. Such is not the 
scope of these observations. But it may with truth be affirmed, that 
until an examination has been allowed, a serous discharge has often been 
thought to be the proof of a malignant disease of the os, when it has 
really been only leucorrhceal ; and a discharge of pus, mixed with blood 
and slightly odorous, has equally often excited painful anxiety, lest struc- 
tural disease existed, when, in fact, neither the finger nor the speculum 
could detect any such mischief. . 

Let it, however, be understood, that long-continued otfensive, muco- 
purulent, and sanguineous discharges are unfavourable signs, espe- 
cially when attended by emaciation and local pain ; nor -must it be tor- 
gotten, if such discharges are accompanied by increasing aggravation 
of general and local symptoms, an unfavourable opinion must be en- 
tertained, till the Droper inquiry, not confirming, may perhaps entirely 
remove it. The examples of persistent discharges, least likely to be 
associated with uterine structural change, are those which occur prior 
to and during the period of catamenial decline. It is not rare for these, 
even of unfavourable character, to continue many months, I had almost 
said for several years, and yet to cease entirely, on the final disappear- 
ance of menstruation. Still, such cases as are detailed (page 117), and 
many such exist, ought to induce great caution, not only in determin- 
ing what the affection really is, but likewise, if there be a strumous 
diathesis, or if near relatives have suffered from glandular or malig- 
nant glandular disease, what are the chances of ultimate recovery. 
Thus, it may be inferred from these practical remarks, that while there 
are many instances in which the uterine and vaginal discharges, al- 
though long continued, yet not having assumed any offensive or sangui- 
neo-purulent character, enable us to pronounce a correct and favourable 
opinion, there are likewise not a few of greater interest, responsi- 
bility, and complication, in which the prudent practitioner will abstain 
from giving any definite intimation as to their real nature, or from 
pledging himself to any positive prognosis, without the aid w^hich an 
examination by touch, or the speculum, can alone supply. Of course, 
in the detailed histories of the organic diseases on which we are 
now entering, especial regard will be paid to the peculiarities of their 
discharges. 



PROGNOSIS. 



There are scarcely any diseases, if we except structural tumours of 
the mammaB, in which an opinion is so anxiously sought, as in cases 



ORGANIC DISEASES OF THE UTERINE SYSTEM. 205 

of uterine growth. If it be suspected that there is cancer of the womb, 
alarm is instantly excited, and the popular and well-founded dread of 
this fatal malady, prompts that particularity of inquiry, which it is 
always difficult and sometimes impossible to evade. Often, when I 
have thought I had parried these pertinacious questions by some en- 
couraging remarks, as to the probability, that although the disease 
might not be curable, yet that, by proper treatment, it would not se- 
riously interfere, at least for a considerable time, either with the com- 
fort or life of the sufferer, the inquiry has been renewed in a still more 
searching form. Frequently has the remark been made, " If this be 
really the same disease as cancer, it must eventually be fatal; and 
what equivalent advantage can accrue from the use of remedies, espe- 
cially of those involving suffering and personal sacrifices?" Thus, on 
the very threshold of the treatment, perplexity arises, and there is a 
fear, lest in the attempt to uphold the hope and energy of the patient, 
our own character for truth, foresight, and diagnostic accuracy may be 
compromised. There are few women who could endure the sudden 
divulging of the real nature of such a malady as cancer, without most 
injurious depression ; and there are certainly not many, who, with a 
conviction of its fatality, like the sword of Damocles, impending over 
them, could practise as they ought, and pursue as they must, for any 
beneficial purpose, the self-denial, on which its restraint so mainly de- 
pends. Although it is visionary to suppose that advanced carcinoma 
is curable, and although the expression of such an opinion would 
justly expose us to the imputation of a lamentable deficiency of sober- 
ness and truth, still the door of hope must not be entirely closed. We 
may fail to cure, yet may we protract life and relieve pain. The ad- 
ventitious formation cannot be removed ; but there are circumstances 
connected with its further growth, which, in the early stages of scir- 
rhus, one of the most common species, may justify a hopeful prognosis. 
It may, too, be urged, as a further ground of encouragement, that 
although these affections are malignant, originating in vitiation of the 
constitution, converting neighbouring parts into their own diseased 
structure, and eventually destroying life by ulceration, hemorrhage, 
and emaciation ; yet that they are generally slow in their progress. 
As affecting the uterus, scirrhus is happily more frequent than any 
other species ; and however much of scientific controversy there may 
still be, as to its precise pathology : whether the views of Hodgkin be 
more correct than those of Baron, Carmichael, or Cruveilhier ; or 
whether the opinions of Muller be more accurate than any of them, — 
it is practically true, that the affection is ordinarily, and judging from 
my own daily observation, 1 might almost say, invariably, of tardy 
development. No one ought therefore to hesitate, especially in the 
early stages, to employ preventive and palliative means. Nor must it 
be forgotten, that there may be organic disease of the various parts of 
the uterus, without malignancy. There may be deposited, for instance, 
in the cervix, a distinct and hard tumour, the result of previous chronic 
inflammation ; or the edges of the os may be indurated and puckered 
from the same cause ; or there may be general enlargement of the 
cervix, with a hardness approaching to that of scirrhus, entirely as 
14 



206 ORGANIC DISEASES OF THE UTERINE SYSTEM. 

the consequence of inflammation following frequent childbirth and con- 
tusions of the part ; and T scarcely know any practitioner who could 
at once accurately diagnose these various states ; and there are few pos- 
sessing the advantages of extended observation, either in hospitals or 
in private practice, who w T ould hazard the happiness of the patient or 
their own reputation, by an early and unfavourable opinion. In such 
examples it is right to treat the case as though it were not malignant 
disease ; and, at all events, for a time to give an assurance, a most im- 
portant item in the treatment, that whatever else the disease may be, 
it is not cancer. Many such conditions I have seen removed en- 
tirely, by iodine and local depletion. The terms " sooner or later" 
are in their usual acceptation of wide import ; but, in reference to the 
progress of disease, and especially of uterine scirrhus, their range is 
exceedingly extensive. If, then, by able prophylactic management, 
the growth of a malignant uterine tumour can be prevented for five, 
ten, or twenty years, it is scarcely possible that too great a sacrifice 
can be made for such a boon ; nor will patients often complain, if such 
an advantage is only partially realized, of the self-denial involved in 
a long-continued horizontal posture, sexual abstinence, spare diet, and 
the avoidance of either physical or mental fatigue. Let it, however, 
be understood, that it will be unwise to encourage higher expectations. 
Restraint of the growth within its present limits, the soothing of pain, 
the avoidance of mechanical pressure on neighbouring parts, if the 
tumour be not large before these means are commenced, may gene- 
rally be insured; but if, from any motive, more than this be promised, 
the patient will be deceived, and an early withdrawal of her confi- 
dence, and the abandonment of the prescribed plan of treatment, will 
assuredly ensue. 

From these remarks it may be inferred, that the prognosis in ute- 
rine organic diseases requires much deliberation ; and that practitioner 
will best consult the welfare of his patient and his own character for 
professional sagacity, whose prognostications are guided by the facts, 
rather than by the theories of these serious maladies ; and w T ho, while 
fully aware of the ultimate danger of malignant diseases, nevertheless 
remembers, that occasionally w T hen a quickly fatal issue has been 
predicted, marked relief, or at least many years of life, not without 
comfort and sometimes even of enjoyment, have falsified the too un- 
favourable and hasty opinion. 

PATHOLOGY, 

From what has been said in the preceding section on prognosis, the 
reader will have concluded, that every organic affection of the uterus 
is not cancerous. If the contrary were true, and every increase of 
bulk and induration were malignant; then, not only would the same 
pathology explain every structural deviation, but the diagnosis also 
would be invariably easy. But this is not so : for there are enlarge- 
ments and indurations, the immediate consequence of inflammation; 
and there are states of the uterus, and especially of its cervix, of 
which more permanent increase of bulk and hardness are the attendant 



ORGANIC DISEASES OF THE UTERINE SYSTEM. 207 

signs, which cannot fairly be attributed to a cancerous diathesis. 
Vascular congestion, arising from various causes, dysmenorrhcea, ir- 
ritable uterus, too frequent intercourse, and difficult and frequent child- 
bearing, may lay the foundation of change of structure without ma- 
lignancy. Doubtless, if there be predisposition to adventitious hetero- 
logous formations, such causes will favour their development ; but if there 
be no such constitutional tendency, these unhealthy states may continue 
long without assuming an incurable character. In women, the mothers 
of numerous families, I have several times, independently of any change 
in the body of the organ, found the cervix large and hard ; and when 
treatment had been long laid aside, I have, years afterwards, ascer- 
tained that although these conditions continued, yet that there was no 
development of malignancy. Such facts should certainly check hasty 
and unfavourable opinions of uterine tumours ; and if they have their 
due weight, a more diligent and efficient treatment will be secured. 
It is indeed with a view to therapeutics that they are introduced ; for 
some practitioners regard every alteration in the form, size, and con- 
sistence of the neck of the womb, as so irrefragable a proof of in- 
curable disease, that persevering, active, and able treatment is scarcely 
thought of, still less practised. 

On growths of the uterus decidedly malignant, much has been writ- 
ten. Numerous and distinguished authors have devoted themselves 
to researches on this important subject, and many excellent and elabo- 
rate works claim the attention of the student of this department of pa- 
thology. r 

It might be curious and somewhat amusing, to recapitulate the va- 
rious theoretical opinions on the nature of cancer, from Hippocrates 
downwards, to Mullerand Walshe ; but I am not aware that any prac- 
tical knowledge would be thus obtained. To say, that Hippocrates 
regarded the disease as of invariably fatal issue, and that Galen thought 
its cause was black bile ; that Paulus Egineta attributed it to the gross- 
ness of the humours, and that Heurnius believed there were two poi- 
sonous principles in cancer, the one of a putrid, and the other of a 
corrosive nature, is] saying little more than that crude speculation oc- 
cupied the time and the minds of these observers, to the exclusion of 
rational and strictly accurate pathological inquiry. Nor must it be 
expected in a practical work of this kind, that the numerous and dis-~ 
puted topics connected with the subject of cancer, shall be elaborately 
discussed. So far as the disease appertains to the female organs of 
reproduction, it claims attention ; and without perplexing or fatiguing 
the reader, I trust its chief and most important points may be hereafter 
sufficiently illustrated. . 

To Dr. Walshe the profession is under great obligations for. per- 
haps, one of the ablest and most complete essays on cancer ever pub- 
lished ;* and we trust no long time will elapse, ere its accomplished 
author presents it to the medical world as a distinct work. Few pa- 
thologists I presume, will question the accuracy of his definition of 
this formidable malady. « Cancer," he says, « is a disease anatomi- 

* Vide Nos. 6 and 7 of the Cyclopaedia of Practical Surgery. London, 1840. 



208 ORGANIC DISEASES OF THE UTERINE SYSTEM. 

cally characterized by the presence of scirrhus, encephaloid or colloid, 
originating in a general vitiation of the economy, and possessing the 
properties of assimilation, of reproduction, and of destroying life by a 
peculiar cachexia." Many authors hare approached the comprehen- 
siveness of this definition; and if the disjointed facts scattered through- 
out various works, were nicely analysed, and placed in juxtaposition, 
they would confirm its simplicity and general truth. It is thus as- 
sumed, that cancer or carcinoma is a genus, and encephaloid, scirrhus, 
and colloid, are regarded as species. If the reader will peruse the ac- 
companying tables of Dr. Walshe, he will find not only the varieties 
of the three species, but also their various symptoms; and when he 
has carefully studied the characteristics of each, he will concur in the 
opinion, that " great as the number and varieties of these distinctive cha- 
racters of encephaloid, scirrhus, and colloid are, they are insufficient 
to counterbalance the weighty reasons afforded by the following facts, 
for uniting them into a genus; reasons which induce some eminent 
pathologists to regard them as one and the same formation primarily: 
1. The different species are found coexisting in different organs in 
the same subject. 2. They are even met with in one and the same 
organ, in close proximity. 3. After the ablation of a cancerous tu- 
mour, the re-produced growth frequently belongs to a different species 
from the original. Thus encephaloid follows scirrhus ; scirrhus more 
rarely encephaloid (Muller); appears in distant parts, after the re- 
moval of colloid. 4. In the hard state, encephaloid and scirrhus are 
not to be distinguished by their physical characters. 5. Structure, 
possessing the appearance of scirrhus, may soften into true cerebriform 
pulp." 



ORGANIC DISEASES OF THE UTERINE SYSTEM. 



209 



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210 



ORGANIC DISEASES OF THE UTERINE SYSTEM. 



It will be seen by this table that carcinoma is distinguished as an 
adventitious heterologous tissue. The circumstance of being a tissue 
susceptible of undergoing all the changes of increase and decay, is one 
of its important features. The characteristics of the three species of 
the disease are thus tabularly exhibited :— 



Enc phaloid. 

Resembles lobulated cerebral 
matter. 

Is commonly opaque from 
its earliest formation. 
Is of dead white colour. 

Contains a multitude of mi- 
nute vessels. 

Is less hard and dense than 
scirrhus. 

Is frequentfy found in the 
veins issuing Irom the diseased 
mass. 

The predominant microsco- 
pical elements areglobular,nol 
always distinctly cellular, and 
caudate corpuscula. 

Occasionallyattains an enor- 
mous bulk. 

Has been observed in almost 
every tissue of the body. 

Very commonly coexists in 
several parts or organs of the 
same subject. 

Is remarkable for its occa- 
sional vast rapidity of growth. 

Is frequently the seat of in- 
terstitial hemorrhage and de- 
position of black or bistre-co- 
loured matter. 

When softened into a pulp 
appears as a dead white or 
pink opaque matter of creamy 
consistence. 

Sub-cutaneous tumours are 
slow to contract adhesion with 
the skin. 

Ulcerated encepbaloid is fre- 
quently the seat of hemor- 
rhage, followed by rapid fun- 
gous development. 



The progress of the disease 
after ulceration is commonly 
very rapid. 

Is the most common form 
under which secondary cancer 
exhibits itself. 

Is the species of cancer most 
frequently observed in young 
subjects. 



Scirrhous. 

Resembles rind of bacon tra- 
versed by cellulo-fibrous septa. 

Has a semi-transparent glos- 
siness. 

Has a clear whitish or bluish 
yellow tint. 

Is comparatively ill supplied 
with vessels. 

Is exceedinglyfirm and dense. 



Has not been distinctly de- 
tected in this situation. 

The main microscopical con- 
stituents are juxtaposed nu- 
clear cells ; caudate corpuscula 
do not exist in it. 

Rarelyacquires largerdimen- 
sions than an orange. 

Its seat, as ascertained by 
observation, is somewhat more 
limited. 

Is not unusually solitary. 



Ordinarily grows slowly. 

Is comparatively rarely the 
seat of these changes. 



Resembles, when softened, a 
yellowish brown semi-trans- 
parent gelatinous matter. 

Scirrhus thus situated usu- 
ally becomes adherent. 

Scirrhous ulcers much less 
frequently give rise to hemor- 
rhage, and fungous growths 
(provided they retain the scir- 
rhous character) are now more 
slowly and less abundantly de- 
veloped. 

There is not such a remark- 
able change in the rate of pro- 
gress of the disease after ulcer- 
ation has set in. 



Is much less common before 
puberty. 



Colloid. 

Has the appearance of parti- 
cles of jelly inlaid in a regular 
alveolar bed. 

The contained matter is 
strikingly transparent. 

Greenish yellow is its pre- 
dominant hue. 

(Its vessels have not been 
sufficiently examined as yet.) 

The jelly-like matter is ex- 
ceedingly soft : a colloid mass 
is, however, firm and resisting- 

The pultaeeous variety has 
been detected in the veins. 

Is composed of cells ia a 
state of emboitemenU 



Observes a mean in this re 
spect. 

Has so far been seen in a 
limited number of parts only. 

Has rarely been met with in 
more than one organ. 

Grows with a medium degree 
of rapidity. 



Undergoes no visible change 
of the kind. 



Has so far been observed in 
adults only. 



With these general observations, I pass on to the next chapter, reserv- 
ing for distinct consideration, in their proper places, facts and theories, 
necessarily bearing on cancer, as occurring in the female organs of re- 
production. 



CHAPTER II. 

Anatomical arrangement of the various structures composing the 
uterus, is the key to the successful study of its pathology; for each of 
these parts may, independently of the rest, be the seat either of func- 
tional disturbance or organic lesion. Nor is it less true, in reference 
to uterine growths even of the same genus and variety, that their de- 
velopment is greatly modified by the part of the organ in which they 
may happen to be placed. In accordance with such views, I shall 
classify these tumours according to their locality. Thus, tumours of 
the uterine walls, including the parenchyma of the organ, will be sepa- 
rated from the more malignant growth of the os and cervix ; and these, 
again, will occupy a place in the classification, distinct from the pedi- 
culated and carcinomatous productions of the lining membrane of the 
uterus. By such a division, the diagnosis, the pathology, prognosis, 
and treatment of every lesion, will be correctly distinguished, and there- 
fore better understood. 



OF THE TUMOURS OF THE WALLS OF THE UTERUS, CHARAC- 
TERIZED BY INDURATION. 

Definition. — These are always either of fibrous, cartilaginous , • or 
calcareous hardness, varying in size from a pea, or a small nut, to the 
volume of a pregnant uterus of the later months. They exert only a 
slight influence on the constitution, and frequently exist almost unno- 
ticed, till, by their magnitude, they press upon neighbouring structures 
mechanically interfering with their functions; inflammation and its 
consequences may then ensue. Their malignancy is denied by many ; but 
there is probably sufficient evidence of their belonging to the scirrhous va- 
riety of carcinoma. 

There are two examples of these growths, deserving to be distin- 
guished from each other. 

First. Tumours, whatever be their size or induration, growing exter- 
nally, and by projecting the peritoneal coat of the uterus, obtaining from 
it an external covering. 

Second. Tumours often, although not constantly, of moderate indura- 
tion and bulk, which, by growing internally, carry before them, and are 
thus invested by the mucous membrane lining the uterine cavity, and 
hence obtain the name of sub-mucous tumours. It need scarcely be re- 
marked, that they are accompanied by an enti7*ely different class of symp- 
toms. 



212 TUMOURS OF THE WALLS OF THE UTERUS. 

As preliminary to further remarks, it may be advisable to recapitu- 
late some of the numerous synonyms of these tumours. By many au- 
thors the names of fibrous or fleshy tubercle have been used: doubtless, 
because their texture was, in the specimens examined, softer than 
usual. By others they have been denominated, scirrhous cancer, scir- 
rhous uterine growth, carcinoma simplex vel fibrosum, stone cancer, &c. 
And when their pathology is examined, satisfactory reasons may, I 
think, be adduced to show, that, by whatever name they are designated, 
they ought to be regarded as malignant, although occupying the lowest 
place amongst adventitious heterologue formations. 

History and Symptoms. — As these more indolent growths, may be 
either single or diffused through several portions of the uterus; as they 
may be either wholly imbedded in the proper structure of the organ, 
or only connected with it through the medium of a peduncle of greater 
or less extent and firmness; as they may be of fleshy and fibrous, or 
of cartilaginous, and even of calcareous hardness; as their size may 
be only that of a marble, an orange, the fetal or adult head, or even 
of the impregnated uterus, nearly at the close of gestation; it follows, 
that the attendant symptoms must correspondingly vary, although the 
character of the inconveniences they produce is tolerably uniform, 
For, while in their early stages they rarely interfere, either with the 
nervous sensibility of the womb, or by their size derange the position 
or functions of neighbouring viscera; so, when their volume is greatly 
increased, mechanical pressure on the surrounding structures, and its 
consequent evils, seem, except in some rare cases, to comprise the 
whole of the mischief. Still, it must be allowed, there are cases where 
pain in or about the tumour itself, is a frequent source of complaint. 
This may arise from pressure on a nerve, or on some of the adjacent 
parts, from the more cancerous character of the growth itself, from 
changes connected with its further development, or from diseased ac- 
tion in some part of its structure. In such instances, the constitution 
is more implicated, there is frequent fever, indigestion, and constipated 
bowels; a quicker pulse, and slight but progressive emaciation. In 
some women the growth attains a certain size and induration, and is 
afterwards quite stationary, neither its dimensions nor condition under- 
going any further change; such patients, as already observed, suffering 
little beyond the inconvenience of weight and occasional pressure. In 
the hospital and private practice, many such cases are within my recol- 
lection ; and where for years to come, judging from the past, neither 
the moderate enjoyment, nor the usual duration of life, appears likely 
to be at all curtailed. 

But this, unfortunately, is not the invariable course of these lesions ; 
as, occasionally, after months or years of inactivity, a period at length 
arrives, when their growth and the results of it are so conspicuous 
and decisive, as to demand all the prompt and efficient relief we are 
able to give. In such states I have found the iodine extremely useful, 
always excepting in utero-gestation. To some who have not studied 
and observed the course and results of these tumours, it may appear 
singular, that conception should occur: but let it be remembered, that 
they interfere only slightly with the general health, menstruation being 



TUMOURS OF THE WALLS OF THE UTERUS. 213 

almost as regular as when the uterus is not structurally diseased. It 
is remarkable, also, that pregnancy occasionally takes place when 
these growths have existed for years, and when that period has ar- 
rived at which the faculty of conception might be supposed to have 
almost ceased. 

Nor is it to be forgotten that pregnancy in such a condition of the 
viscus, is imminently dangerous. The tumours soften during the later 
months ; the increased vascular supply leads to inflammation ; un- 
healthy suppuration is established ; and death generally occurs, if the 
tumours be of large size, soon after parturition. These facts and the 
inferences deducible from them, first, I believe, pointed out by myself, 
have now, I think, produced their just impression. Formerly, when 
they were propounded, and when premature labour artificially in- 
duced, was, under certain conditions, proposed as the appropriate 
treatment for pregnancy so complicated, the remedy was regarded as 
of doubtful value ; but of late, the prejudice has greatly subsided, and 
the argumentative and practical observations of Dr. Ingleby, in his 
able work on Obstetric Medicine, have gone far to elicit the truth of 
my views and to corroborate the practice founded on them. 

It need hardly be mentioned, that these tumours rarely attract 
much attention, till, by their bulk, they either project the abdominal 
coverings, or partially prevent the easy evacuation of the bladder or rec- 
tum. Such inconveniences, and the pressure and contusion of neigh- 
bouring viscera, are frequently aggravated by excessive induration of 
the encroaching growth ; or, if the tumours have, from repeated in- 
flammation, contracted firm adhesions, they may become fixed, and 
almost immovable, and thus occasion distressing local tension, and 
almost constant pain. Pathological changes also, unconnected with 
increased bulk, are occasionally occurring. I do not refer to softening, 
which is generally appreciable, but to increased induration, even to 
the extent of cartilaginous, or calcareous hardness. Ossification com- 
mencing with the central portion of scirrhous tumours^ and spreading 
thence to their periphery, is said occasionally to convert the whole 
mass into bone. M. Trousseau has frequently observed this mutation 
in bitches ; and instances scirrhus of the uterus, as being especially 
prone in the human subject to such conversion. Breschet regards 
" conversion into bone or cartilage," as affording evidence of exces- 
sive activity of nutrition in the transformed part ; while Hodgkin, with 
much more truth, considers osseous formations comparatively more 
rare in encephaloid than in scirrhus, and attributes this to the greater 
vitality of the former. Dr. Walshe believes, that if we exclude from 
consideration the bony lamellae actually continuous with some part of 
the skeleton, and which form a marked characteristic of certain can- 
cers connected with osseous structure, the phenomenon in question 
will be found to have been much more written of than observed. 

Pathology. — I may perhaps be censured, for having thus associated 
the fibrous and hard growths, so often developed in the parenchyma, 
or serous or mucous investitures of the uterus, with malignant diseases. 
I know that a contrary opinion is held by some able men, amongst 



214 TUMOURS OF THE WALLS OF THE UTERUS. 

whom may be mentioned Meckel, Laennec, Andral, Lee, Carswell, and 
Bayle. The last-named pathologist and Lobstein, have indeed placed 
fibrous tumours amongst those adventitious structures incapable of be- 
coming the seat of carcinoma ; a position, however, formally denied by 
Dupuytren, and by our distinguished countryman Dr. Hodgkin. It would 
not accord with the practical intention of this work, to enter at length 
into the difficult and complicated, and yet deeply interesting questions 
involved in the anatomy, physiology, and diagnosis of the varieties of 
cancer : but yet I must avow my conviction, after a careful and re- 
newed examination of these tumours, that they are genuine cancerous 
productions. The following reasons appear to me conclusive: — 1. 
They possess the structure of compound adventitious cysts, the basis 
of the class of heterologue formations. 2. In the colour of the con- 
tained mass, and in the arrangement of the membranous septa or 
bands, the containing tissue ; they are identical with scirrhus. 3. In 
hardness, occasionally justifying the application to them of the term 
stone cancer ; they are not to be distinguished from the varieties 
of carcinoma already mentioned. 4. They occur very frequently in 
conjunction with growths of undoubted malignancy in other parts of 
the uterus. 5. And lastly, they possess one especial attribute of ma- 
lignancy, incurability. 

It may be urged, that, definite as are these conditions, the sum of 
them does not endow these growths with the power to assimilate dif- 
ferent tissues to their own substance, nor with the capability to produce 
that peculiar cachexia by which cancer destroys life. No one can 
deny, that the hard or fibrous tumour is the predominant organic dis- 
ease of the walls of the uterus ; and it must be granted, owing to their 
simpler structure as compared with the cervix, and the relation which 
always exists, as to malignancy, between adventitious growths and the 
texture in which they are produced, that an indolent and benign cha- 
racter generally appertains to this variety. Still there are more points 
of resemblance to carcinoma than might be supposed ; for these growths 
do occasionally disorganise the structure of the uterus, as may be seen 
by preparations in our different Museums, and they often destroy life 
(vide Cases) by that softening, degeneration, and breaking down, w T hich 
can hardly be called ulceration, but which is peculiar to cancer. In 
many examples, also, one of which will be narrated, a fatal issue oc- 
curs in connexion with, and apparently as the result of the cachexia 
of malignant disease. And, lastly, I believe it would be difficult, if 
not impossible, supposing the diseased masses to be removed from their 
respective sites, to distinguish between a so-called fibrous tumour and 
a genuine carcinomatous tubercle. On one occasion, I made sections 
of growths, coexisting in the same individual, taken from these distinct 
localities, and scarcely any appreciable difference could be discovered 
in their structure and arrangement ; although, certainly, from the cut 
surface of the tumour of the cervix, there was a freer exudation of 
cancerous ichor. Notwithstanding these points of similarity, it is pro- 
bable, that the differences happily existing in the progress and termi- 
nation of the two varieties, will still be viewed by many as justifying 
the exclusion of fibrous tumours from the class of cancerous diseases. 



TUMOURS OF THE WALLS OF THE UTERUS. 215 

For the Diagnosis and Prognosis, reference must be made to pages 
193 and 204, premising only, that it is often exceedingly difficult, 
where the growth, occupying the abdominal cavity, is large, filling 
perhaps its greater portion, to determine whether the uterus or ovary, 
or both, may not be diseased. Occasionally, after repeated examina- 
tions, even by those accustomed to make them, and a careful appre- 
ciation of all the signs, a positive diagnosis can scarcely be made. 

Treatment. —It has already been stated that cancer is incurable ; but 
this declaration, although essentially true, requires qualification, lest it 
prevent all effort for its relief. Still it is not intended to be affirmed, 
that we possess any remedy by which the general vitiation of the sys- 
tem, on which cancer depends, can be neutralized ; nor that the dis- 
ease is more than very rarely removed by resolution. But it may be 
granted, in external cancerous tumours, that iodine, and probably other 
medicines also, as the preparations of lime, conium, arsenic, mercury, 
&c, have occasionally effected absorption, although perhaps, as a co- 
incidence only, or at most as the consequence of some change of nutri- 
tion, equally beneficial with a cure : still, if by reference to s & uch effects, 
and to those equally fortunate arising from operation, it be affirmed, 
that the complaint could not have been cancerous because it was cured, 
then the question is at once concluded, and the issue unfairly decided, 
neither reasoning nor unprejudiced observaticn being allowed any 
adequate scope. 

There can be little doubt that cancer has an inherent tendency to 
grow, and not to melt down or resolve. And yet it is to this espe- 
cial point of treatment, and to the attempt, by medicine and diet, so 
tar to improve the general health as to prevent further increase, that 
1 wish principally to direct attention. 

Mr. Travers states, « that the solution of chloride of lime effected 
the absorption of a large tumour, in the course of some months, re- 
garded by competent authorities as scirrhus, in a lady whose other 
breast had been extirpated for that disease. Not long after, she died 
of asthma from diseased lungs; the scirrhous tubercle appearing not 
only in the chest, but in several of the abdominal viscera." 

Dr. Walshe, also, whose testimony in confirmation of my own views 
of the remedial value of iodine, first promulgated in 1835 in Guv's Hos- 
pital Reports, I gladly re-publish, remarks, " that the external use of 
this drug, in the form of ointment, sometimes completely removes tu- 
mours, possessing the characters of scirrhus, where it has been had 
recourse to at an early stage of their development, is a fact of which 
we have witnessed some examples. The truly cancerous nature of 
such growths may of course be questioned ; yet a trial of iodine exter- 
nally, provided the part be indolent, and its use excite no irritative ac- 
tion m the tumour, is certainly advisable : the length of the trial should 
be regulated by the apparent influence produced on the tumour \n 
excellent ointment is composed of five grains of iodine and a drachm of 
the loduret of potassium, to an ounce of prepared lard. The ioduret 
of lead is sometimes well borne, where the former combination proves 
irritating." r 

That this substance exerts, almost invariably, a very marked influ- 



216 TUMOURS OF THE WALLS OF THE UTERUS. 

ence over the glandular system, admits of no doubt. Serres, Magen- 
die, and Dumeril, in their Report addressed to the Royal Academy 
of Science, on a Memoir by M. Lugol, on the use of iodine in scrofu- 
lous diseases, remark, « that, applied externally, its local action has 
always been very sensible : it excites on the surfaces of ulcers i a feeling 
of smarting accompanied with painful itching. This application to the 
diseased surfaces changes their appearance, and frequently produces 
as appreciable an effect as that produced by mercury on venereal ulcers. 
However, the mode of its action does not appear to be invariably the 
same. Sometimes the iodine seems to melt down, and resolve Me tu- 
bercles. Sometimes, on the contrary, it urges them on to rapid sup- 
puration. Iodine (say the reporters) has never, in the diluted form, 
caused emaciation, nor produced expectoration of blood, nor other 
accidents which many have imputed to its action. ' J 

I have used iodine in diseases of the body, the mouth, and neck ot 
the womb, and the different success has been precisely what might 
have been expected. In the walls of the uterus, which are not glan- 
dular, it has generally restrained the activity of the disease, confining 
its bulk within the limits it had attained prior to its exhibition ; and 
after watching some of these cases for several years, there has been 
no increase of the affection. . 

The inferences I have drawn from the use of this medicine are as 

follows : — , 

First—Its internal administration, and its use, by inunction, is de- 
cidedly beneficial ; the advantage, if the remedy be judiciously em- 
ployed, being rarely attended by constitutional injury. 

Secondly— -In hard tumours of the wails, or cavity of the uterus, 
resolution, or disappearance, is scarcely to be expected; since the 
growths are adventitious or parasitic, and are not imbedded in glan- 
dular structure. Here the prevention of further deposit— in other 
words, the restraint of the lesion within its present limits, and the 
improvement of the general health— will be the extent of the benefit 

derived. 

It must not be supposed that the use of the iodine is empirically to 
preclude the employment of other means : cupping on the loins ; a mild, 
animal and unstimulating, and often, for a time, a milk diet ; gentle ape- 
rients, and the warm poppy hip-bath, are important adjuvants. In the 
appended cases it will be seen that I have employed leeches and 
setons, with marked advantage ; and there can be no doubt that sex- 
ual excitement must often exercise a prejudicial influence. 

Second.— Sub-mucous tumours, usually, although not invariably of 
moderate induration and bulk, growing internally, and obtaining a 
covering, not from the 'peritoneum, but from the mucous membrane 
lining the uterine cavity, and giving rise to different, and certainly 
more immediately dangerous consequences. 

History and Symptoms.— This is an interesting and important va- 
riety. In the majority of instances, hard or fibrous tumours grow 
externally, and rarely, and according to some authors, never, either 
ulcerate or bleed ; but these sub-mucous growths, by their increase in 
size distend the uterine cavity ; and stretch and irritate the mucous 



TUMOURS OF THE WALLS OF THE UTERUS. 217 

membrane, and thus give rise to frequent, excessive, and fatal he- 
morrhage. The catamenial secretion also is generally increased, and 
diseased change of the uterine mucous tissue occasionally occurs. 

It is observed, when these tumours can be touched during life, that 
they are sensitive and painful, unlike polypi : and after death they are 
found to possess, either a laminated and fibrous texture, or the stony 
hardness of real scirrhus. It is rare to find these tumours thus en- 
croaching on the uterine cavity ; for of thirty examples, in Guy's 
Museum, there are only three, at the most four, where the growth is 
so placed. Thus it may, I think, be assumed, that the location of 
them now mentioned is unusual; and, if so, hemorrhage from such 
growths will, of necessity, also be unusual. Cruveilhier and Dupuy- 
tren have probably been misunderstood by those who suppose that 
they regarded such an event as frequent. Certainly, if this be their 
conviction, it is opposed to the opinions of most pathologists. 

Discharges of blood therefore from the uterus, continuing longer 
than the common losses connected with catamenial derangements, may 
arise not only from an inflammatory or congested condition of the 
viscus itself, from polypi, or from growths more decidedly vascular 
and malignant, but from hard or fibrous tumours. It has been long 
well known, that these growths rarely ulcerate, excepting when they 
occupy the mouth or neck of the uterus ; but it is a fact more recently 
established, that they give rise to bleedings of a continued, alarming, 
and fatal character: and further, after death, that the mucous mem- 
brane covering them, may be entirely free from ulceration, or even 
abrasion : thus tending to confirm an opinion which I entertain, that 
the bleeding is principally, if not entirely, furnished by the tissue co- 
vering the surface of the tumour, rather than by the tumour itself. 

The peculiarity of these examples consists in the occurrence of the 
bleeding prior to ulceration ; so that we must always bear in mind, in 
hemorrhage from the unimpregnated uterus of unusual frequency, re- 
sisting the most judicious and persevering treatment, that there may be 
a tumour of the kind now described distending the cavity, and out of 
the reach of the finger, maintaining so congested and inflammatory a 
condition of the mucous membrane, as almost to render these bleed- 
ings necessary for its partial relief. 

The statistical facts already adduced lead to the belief, that these 
are, happily, singular cases ; yet it is valuable to know, that such a 
cause really exists; as it may lead to greater diligence in the use of 
early, and perhaps antiphlogistic remedial measures. 

It has of late been assumed, that there is much similarity between 
hard and fibrous tumours and uterine polypi : and, on distinguished au- 
thority, it has been affirmed, " that they not unfrequently become ute- 
rine polypi, simply by descent, and the consequent formation of a stalk." 
That there are points of similarity between the two diseases, although 
they have probably been overrated, I do not question ; but that a genuine 
hard or fibrous tumour ever becomes a pediculated polypus, I can 
scarcely believe. Guy's Hospital Museum does not supply a speci- 
men of such a change. That one of these hard fibrous tumours may 
very rarely find its way into the uterine cavity, is allowed, because 



218 TUMOURS OF THE WALLS OF THE UTERUS. 

the statistics of the disease prove it; and that prior to the patient's life 
or her powers being destroyed by the bleedings, which, in this situation, 
the tumour may occasion, the growth may, as a most unusual occur- 
rence, descend to the lowest part of the uterine cavity, distend and pass 
through its cervix, and ultimately find its way into the vagina, may 
also be conceded ; but it will be a hard or fibrous tumour still, although 
its altered situation, and the bleedings attendant upon it, may justify 
and even demand its removal by the same means as in polypus. 

In structure, with some few exceptions ; in sensibility, both in the 
growth and the surrounding parts ; and in vascularity as well as in 
many other particulars, there is a marked difference between the hard 
or fibrous tumours of the cavity now described, and polypus. 

An inspection of preparations of such morbid growths cannot fail 
to demonstrate how much more distinct, generally, in the tumour, than 
in the polypus, is the induration of texture ; and certainly the white 
membranous lines are much more defined and striking in the former 
than in the polypus. Thus, while it is somewhat rare, except in old, 
large, and condensed polypi, to find this indurated and linear struc- 
ture, a genuine, hard, or fibrous tumour, except when breaking down, 
is never without it. 

In the number of the growths there is decided similarity: it is 
common to meet with many hard tumours in the same uterus, while it 
is very rare to find more than one polypus. 

In the method of growth there is a conspicuous distinction. The 
polypus, probably because it is not malignant, does not affect the or- 
ganization of surrounding parts; the muscular walls of the uterus 
being rarely thickened, however large may be the polypus. The hard 
tumour, on the contrary, may, and often does, convert, by degrees, 
the uterus in its vicinity into its own diseased structure. 

The internal tissue of many polypi is spongy and cellular, and co- 
piously permeable by blood, a circumstance scarcely ever appertaining 
to the hard or fibrous tumour. I was much struck, a few days ago, 
by a preparation in the Museum of St. Bartholomew's Hospital, where 
a hard tumour, imbedded in the walls, had received no injection, al- 
though the vessels in every other part of the uterus were beautifully 
filled ; a circumstance lending something more than probability to the 
opinion I have just now expressed, that the hemorrhage, in these in- 
stances, is furnished by the membrane covering the tumour, and not 
by the growth itself; while, in the polypus probably, with very few 
exceptions, the bleeding occurs from the vessels in its structure : as is 
satisfactorily proved by its texture, and by the difficulty of getting any 
mercury, or other injection, retained in its vessels, however carefully 
it may be thrown in. In the polypus injected by Mr. Sibson and my- 
self, the mercury quickly escaped through the orifices of the vessels 
opening on its surface. Sir Charles Clarke affirms, that if coloured 
injection be thrown into the vessels of the uterus, so as to make the 
substance of the uterus quite red, .none of it passes to the tumour of 
fleshy or hard tubercle. 

The want of sensibility is an almost invariable condition of true 
polypus ; while the hard or fibrous tumour is never entirely bereft of 
sensation. 



TUMOURS OF THE WALLS OF THE UTERUS. 219 

Pregnancy may and often does occur in connexion with hard or 
hbrous tumours ; rarely if ever, when there is polypus except where 
the growth arises from the cervix or os. There are, so far as I know 
very tew such pregnancies on record. 

Other diagnostic differences might be stated ; but enough, probably, 
has been adduced, to show how very dissimilar the two diseases 
really are. 

In the treatment, and its results, there are distinctions worthy of 
notice. J 

There is no remedy for polypus, but removal. Medicine is of no 
avail ; and astringent injections are entirely useless. Nor am I aware 
that a polypus was ever spontaneously cured by absorption. 

A hard or fibrous tumour has once, in my own practice disao- 
peared without the use of any medicine ': and Sir Charfes Clarke men- 

couTd I IT* tK T*" WhCre the , ,Um ° Ur ' aS bi S as a chi!d ' s h ead, 
could be felt through the panetes of the abdomen, just above the pubes • 

upon its surface could be felt two smaller tumours ; one, the size of a 

fTJJ r ^ ° ther twiCe this Size -" The P^ient had laboured 

tor some time under a very profuse discharge of blood from the vagi- 
na A variety of means were employed for the relief of this case, for 
two years. Upon examining the abdomen at the end of this period, 
the tumours could not be discovered ; and after death, the uterus was 
iound as arge as that of a woman at the end of the fifth month of prel! 

Zl| y 't„ m . POn f nteri0r Part ° f k ' Dear the fund,,s > were founil two 
small tumours as large as peas; which were probably the same tu- 

vestile of Th m' "tH* T ^"^ ^T^ ' M ^ ™ no °*er 
l^Ll i • , 6Se tUm ° UrS Were of a hard and listing na- 

ture and were lying between the muscular part of the uterus and the 

rhT™? C T nn , S it " M l- Ca ™ icha el, too, maintains, ha s £ 
rhus occasionally admits cure by resolution. 

The ligature can scarcely be expected to produce equally satisfac- 
tory results ,n both diseases. The sensibility of the hard tumou and 
he probability there 1S that a portion of the uterine structure sha 1 be 

dec S r I T graSP ' Wl1 ' in n duCe l6SS faV0Mable anticipations of 
decided benefi from ,ts use. The hemorrhage is almost invariably 

ture » r , eStralned ( . i « P° lyPUS ^ ^ lhe application of the lig I 

he n'art nf *, , P ° at10 ^ °t ^ P ° rt '° nS ° f mucous membrane than 
the part of it covering the hard tumour, may still maintain continued 

although diminished, loss of blood. ' 

The treatment of these cases is far from satisfactory : palliation in 
most is all which can be expected : still the certainty in some instances 
and the great probability in others, that the hemorrhage depends on 
these growths, w, 1 lead to more c'areful and protracted 3 management 
Entire abstinence from sexual intercourse-as well to avoid the certain 

ment gr must a n ger ° W^' M ,he gr6at ^ hsSer evil ° f ™* - 

oThVTnTvi 7 g y , ent ° rCed u A P at,ent known t0 be thu ^ afTected, 
ought for years to practise such a degree of self-denial. The recrm- 

Sn^T"' a " d , modifi , ed but continued antiphlogistic measures, will 

leZ»L ?"'! \ and th6 , dlet ' althou § h "alritious, should never be 
generous and stimulating. A practitioner in these maladies will be 



220 TUMOURS OF THE WALLS OF THE UTERUS. 

cautious how he employs the secale, as an injection, or as an internal re- 
medy. In my hands, it has appeared to stimulate the raucous mem- 
brane, and to increase the hemorrhage. Narcotics especially in the 
form of suppositories, have been beneficial ; and the poppy and co- 
nium injections into the vagina, used cold, have appeared to restrain 
the bleeding. An aperient, and occasionally a purged condition oi 
the bowels, has had a similar effect. After repeated and extensive he- 
morrhage, these and other measures must be strictly pursued ; nor will 
a disease of this nature allow the sufferer to indulge in much physical 

or mental exertion. _. , 

Life in most instances, where the disease is early discovered or sus- 
pected may be prolonged ; and perhaps with a good measure of quiet 
and passive enjoyment, if the plan now prescribed be sedulously pur- 
sued ; but on no other terms. It is possible that the tumour may tem- 
porarily cease to grow, and that the investing membrane for such pe- 
riod may not be the subject of repeated congestion and inflammation. 
Such appears to have been the result in Case 48. More commonly, 
however, palliation and partial exemption from the bleeding is the ex- 
tent of the benefit obtained. 

How far iodine, aided by mild antiphlogistic treatment, may ac- 
complish a suspension of the diseased action, I do not know; but lam 
favourable to its employment ; nor can I think it impossible that this 
same agent may induce absorption. 

I shall select only a few out of the many cases collected by myselt, 
in hospital and private practice ; preferring those which exemplify the 
usual course and progress of those tumours, and the more efficient 
methods of treatment. And if some of my readers regard their nar- 
ration as unnecessary, I am convinced, from the intimations I have 
received, that the majority think differently, and believe with me, that 
although our knowledge of disease may be based on facts and most 
ably condensed, yet that it will often fail, without the abridged detail 
of carefully recorded cases, to produce a practical and useful impres- 
sion. If proof of the value of such illustrations were necessary, it 
might be found in its near approach to clinical teachiag ; the best oi 
all expedients for imprinting medical knowledge indelibly on the mind. 



Case 42. 

ILLUSTRATING THE EFFICACY OF THE TREATMENT BY IODINE. 

REPORTED BY THE CLINICAL CLERK. 

Mrs. , aged 45, was admitted into Mary's Ward, Guy's Hospital, January 

23 1834 

' She has been married eleven years, without children ; is still menstruating ; 
and has invariably enjoyed good health, with the exception of occasional hysteria. 

Six or seven months ago, she first perceived a small, hard tumour, about the size oi 
an orange, situated low down in the hypogastric region : it produced neither pain nor 
inconvenience, and has therefore been entirely disregarded. 

It is nearly as large as the adult head, reaching some way above the umbl f , ° u J 
and occupying the central part of the pelvic and abdominal cavities. It is loDuiatea, 
but very firm ; and by its pressure, prevents the easy evacuation of the taeces and 



TUMOURS OF THE WALLS OF THE UTERUS. 221 

orine. The os uteri is patulous, hard, and puckered ; the cervix is tender, and ex- 
cessively indurated : pressure by the finger on these parts produces pain. 

The whole uterus is low down in the vagina. This canal is hot: painful on touch 
at its upper part; and there is constantly escaping from it a discharge of white, 
opaque, purulent-looking matter. 

Applicetur Cucurbitulse cruentas tumor, bis, et detrahantur sanguinis 

5x. 
Applicetur Ung. Iodin. cervici uteri, etiam tumori abdominis, more soli- 

to. — Sumat Julep. Iodin. -fj. ter die. 

Feb. 10. She is improved in health. — the iodine makes her giddy. 

March 4. She leaves the hospital to-day, materially improved ; and is to bean 
out-patient. She is more robust in her general health, than when she commenced 
the use of iodine. 

March 22. To-day T have carefully examined her, at my own house. The cata- 
menia appeared, as usual, last week. The tumour, externally, is greatly diminished ; 
not reaching the umbilicus, by at least an inch : it is also much softer, and its tabu- 
lated feel is more distinct and positive. She says, too, that her sensations are greatly 
improved, having lost the feeling of pressure and distention ; and she attributes a 
good deal of the improvement to the recumbent position she has now maintained for 
two months. 

It is, however, internally that the greatest improvement has taken place; the os is 
less patulous; its edges less puckered and irregular; and its induration is so far di- 
minished, as to lead to the hope that, by attentively pursuing the treatment, it may 
be altogether removed. 

April 17. The tumour is getting less, and it is now very movable : it has dimi- 
nished so much, as scarcely to exceed the size of a very large orange: internally, 
the puckering of the os, and the excessive induration of the cervix, are quite re- 
moved ; and 1 should, if examining them for the first time, consider them nearly, if 
not quite, healthy. The iodine does not emaciate, nor nauseate. 



Case 43. 

LARGE HARD TUMOUR ADVANTAGEOUSLY TREATED BY IODINE. 

REPORTED BY THE CLINICAL CLERK. 

Mary , aged 28, was admitted into Guy's Hospital, Match 21, 1833. 

The patient first perceived an enlargement in the right hypogastric region about 
three years since. As it did not produce inconvenience or pain, and was unattended 
with any symptom which alarmed her, she failed to apply for medical advice. During 
the last twelve or eighteen months, she has suffered so severely from lancinating- 
pains, in and about the uterus, attended by strangury and tenesmus, that her health 
is greatly impaired. She states, that the tumour has trebled its size within the last 
three months : it requires a considerable effort to walk. Her stomach is highly irri- 
table ; digestion is imperfectly performed ; and she has gradually lost flesh! Pulse 
110, rather hard: skin hot at night: sleep much disturbed. The catamenia have 
been regular in their recurrence, though their flow has been accompanied with con- 
siderable pain. 

On examination, Dr. Ashwell reports : — 

" I find the uterus nearly of the size of the adult head, and placed on the right side 
of the mesian line, occasioning a visible protrusion of the abdominal parietes : it is 
very hard and unyielding. On the left side there is a hard tumour, projecting pos- 
teriorly, and pressing on the sigmoid flexure; giving rise to the pain complained of 
in that region. On examination, per vaginam, the os is healthy and smooth; but 
there are two hard tumours, about the size of a hazel-nut, attached to the anterior 
part of the cervix, altering its position, and making pressure on the urethra. The 
cejvix is painful, on being touched ; and exuding from it is a purulent acrimonious 
discharge." 

15 



222 TUMOURS OF THE WALLS OF THE UTERUS. 

She was ordered to take Jive minims of the tincture of iodine twice in the day ; and at 
night, the nurse was enjoined to rub a small portion of the unguentum iodin<e over the 
tumours. Castor oil was daily administered, to regulate the bowels : and the local 
pain and irritation were alleviated by an opiate at night. The iodine produced both 
local and general excitement ; and at one period during its employment, an obstinate 
epistaxis supervened. 

A month after admission, when this plan of treatment had been steadily pursued, 
Dr. Ashwell examined and reported : — " 1 find little alteration on the external tumours 
attached to the walls: but those situated on the cervix are softer and resolving; 
though still so far indurated and enlarged, as to occasion mechanical inconvenience." 

It would be superfluous minutely to detail the progress of this case. The iodine 
was perseveringly employed, and was omitted only when its constitutional effects 
were visible. After a lapse of eight months, the tumours on the cervix had entirely 
disappeared, and this portion of the uterus resumed its natural size and character. 
The tumours felt externally, and, which probably occupied a portion of the uterine 
cavity, remained stationary. She remained in the hospital thirteen months, and at 
the expiration of this time she was enabled to walk between two and three miles, 
with comparative ease : her general health had greatly improved, and she had as- 
sumed a more rounded and robust appearance. Accounts have since been transmitted 
by herself; in which it appears she has had no further need of medical advice ; that 
the tumour of the parietes has ceased to enlarge ; and that she is in the enjoyment 
of o-ood health. It is now eight years since she left the hospital. 



Case 44. 
large hard tumours — iodine used beneficially. 

Mrs. , aged 44, consulted me, at the late Dr. Babington's request, on Feb- 
ruary 7th, 1832. She had been married five years, without the occurrence of preg- 
nancy. Her health during three years of that period had been good ; and, even when 
1 first saw her, she had the aspect of a woman free from any serious disease. About 
two years before, she perceived a " hard lump" in the hypogastric region ; which also 
attracted the notice of an eminent obstetric physician, who was at the time attending 
her in an attack of peritonitis. Since March, 1830, the tumour had been entirely 
disregarded ; and she now solicited medical assistance, in consequence of inability to 
walk, impaired appetite, increasing pain in the hypogastric region, and emaciation, 
especially affecting the upper and lower extremities. The catamenia had never been 
interrupted, but their approach was invariably attended with pain. 

On examination externally, I found two tumours : one situated in the right groin, 
low down on the body of the uterus ; and a second tumour, harder and more distinct, 
occupying a large space of the anterior surface of the fundus of the uterus, producing 
an inequality of the abdominal surface, quite visible to the eye. 

By a vaginal examination, the uterus was perceived to be exceedingly enlarged, 
and nearly as hard as cartilage. The os was easily found ; but its situation was 
greatly altered, the enlargement of the cervix (which was lobulated, and very hard) 
pushing it upwards and forwards, so that it pressed on the neck of the bladder and 
urethra ; the edges of the os were puckered, and slightly tender to the touch : and, 
by the speculum, it was seen that they were red. 

The diet was regulated, to consist of milk and animal food, with half a pint, or a 
pint, daily, of mild ale; wine or spirituous liquids being absolutely forbidden. In 
this, and indeed in all the cases where the os and cervix were affected, it was desired 
that marital intercourse should be avoided as much as possible. 

Sumat Tinct. lodin. gutt. v. ex Aqua cum Saccharo permista, ter die. 
Utatur Ung. Iodin. massa instar nucis MoschataB cervici uteri, etiam- 
que tumori abdominis, quaque nocte. 

It would be tedious to pursue this treatment through the six or seven months which 
it occupied. Suffice it to remark, that occasionally, from its peculiar effects, the 
iodine was temporarily suspended. Within four months, the os and cervix were re- 
duced nearly to their natural size ; and the symptoms arising from pressure on the 



TUMOURS OF THE WALLS OF THE UTERUS. 223 

bladder, and interference with the urethra, passed away: there was, however, no 
perceptible diminution of the abdomino-uterine tumour : still, she resumed her usual 
activity ; she walked without inconvenience ; her appetite returned ; and she entirely 
regained her flesh. 

I examined this lady about September, 1835. three years and a half from the com- 
mencement of the treatment, and nearly three years subsequently to laying aside the 
use of the iodine. I found the os and cervix entirely healthy. I was informed that 
menstruation was regularly and naturally performed ; that sexual intercourse was 
not productive of injury ; and that her strength and vigour were entirely re-estab- 
lished. 

During the present year, 1841, this patient has corroborated the above report. In 
June, during my attendance on her husband, who subsequently died, an examination 
was permitted ; and its result was entirely confirmatory of the facts already stated. 

Let it not be thought that this remedy is empirically to exclude the 
agency of other and valuable treatment. Such is not my view, nor 
at all accordant with my observation. All I claim for the iodine, in 
this first class of cases, is just that which I have already stated, viz., 
that in some, indeed in most of the examples in which I have been en- 
abled fairly to employ it, in conjunction with occasional depletion and 
mild diet, it has, at least for a time, arrested the disease, and thus pro- 
cured a temporary exemption from its inconveniences. 



Case 45. 

hard and large tumour of the parietes of the uterus. 

In November, 1840, I met Sir James Clark in consultation on the fol- 
lowing case : — 

Mrs. , set. 40, has been married eleven years, and although pregnancy has 

occurred, she has never borne a living child. Her health has generally been good, 
her temperament lively, and her habits active. During the summer of the present 

year, Mrs. had a severe illness, primarily inflammation of the peritoneum, but 

followed by fever. In the latter part of September, she first discovered an enlarge- 
ment in the hypogastric region, immediately above the brim of the pelvis, and to- 
wards the left groin, which was tender, but not very painful. Soon afterwards, how- 
ever, it became larger, and as there were darlings about the growth, and occasional 
paroxysms of severe suffering, a careful examination was made (Nov. 20th), when a 
growth of considerable induration was discovered. It had risen three or four inches 
Towards the umbilicus; and although it passed a little to the right of the mesian line 
of the body, by far the larger portion was in the left hypogastric region. The cervix 
uteri was swollen, patulous, and indurated in several spots. There was no difficulty 
in relieving either the bladder or the intestines; but there was some emaciation, and 
the pain was sufficient to induce her to keep almost constantly the recumbent posi- 
tion, and to confine herself entirely to the house. 

A light, nutritious diet of fish, chicken, and mutton, with some wine and water, 
was ordered. A mild aperient pill, and the following mixture, were also prescribed : 

R. Ferri Tartrat. Ammon. 3j. Tinct. Iodin. 5ss. Tinct. Card. C. £j. 
Aquae destill. ^vij. M. ft. Mistura. 

One or two tablespoonfuls to be taken twice or three times daily. 

The local measures were, leeches, on alternate mornings, to the tumour; the use 
every night of the hip-bath ; and the constant application, by means of linen com- 
presses, covered by oiled silk, of the poppy fomentation. 

Such was the plan pursued for nearly five weeks, at the end of which time the 
growth had lessened considerably, and there was but slight pain. At this period 



224 TUMOURS OF THE WALLS OF THE UTERUS. 

(January, 1841) the weather was intensely cold, and to derangement of the health 
consequent on this state of the atmosphere, but more especially to excitement, an un- 
favourable change, both in her health and the tumour, was clearly attributable. 

Greater caution, however, was observed, and the morbid enlargement, by the end 
of February, did not exceed the bulk of a very large Seville orange; it having, in 
November, equalled in size a foetal cranium at the full period of gestation. 

During many subsequent months, iodine, internally and externally; mercury, to 
the extent of producing slight salivation ; quinine, and various stomachics and cor- 
dials, were exhibited ; and, in April, the tumour had subsided so much, and appeared 
to be altogether in so quiescent a state, that a seton was inserted over its site, in the 
left hypogastric region. Some weeks afterwards a larger seton was made, nearly in 
the same situation, by Dr. Kirby, of Dublin. Sea-bathing was recommended, and 
when 1 last saw the lady, in August, 1841, her health was greatly restored ; the tu- 
mour was so much lessened as to have sunk quite within the pelvic cavity, the pain 
having almost entirely ceased ; and the cervix uteri was much more healthy. 

I have narrated this case, because it belongs to a large class, and 
because it proves the value, where any doubt exists of the precise cha- 
racter of uterine growths, of cautious and long-continued treatment. 
The pain, emaciation, and stationary condition of the tumour, were un- 
favourable signs: the subsequent diminution of suffering, the gathering 
of flesh, the improved aspect, appetite, and strength, were, on the con- 
trary, results sufficiently auspicious to encourage a further continuance 
of remedies. And although in similar examples, the same means may 
not have been attended with like success, still my conviction of their 
general efficacy is unchanged. We are not expected to determine 
what may be the final issue of such growths, nor to deny the possi- 
bility of eventual malignant development ; nor to promise a cure. But, 
judging from facts, we may honestly declare, that in many such en- 
largements so treated, benefit and retardation of the diseased growths 
have been the consequences of persevering in prophylactic, and occa- 
sionally more active measures. 



Case 46. 

HARD TUMOUR OF THE UTERUS, CURED BY SPONTANEOUS BREAKING DOWN 
OF ITS STRUCTURE, AND DISCHARGE OF THE FRAGMENTS THROUGH THE 
VAGINA. 

COMMUNICATED BT SIR JAMES CLARK. 

The subject of the uterine tumour was a young woman about 28 years of age. I 
first saw her a fortnight after marriage. She then complained of abdominal pain, 
and almost constant nausea. Immediately above the pubis, there could he felt a tu- 
mour about the size of a very large orange; and from the vagina there protruded a 
Small portion of membranous substance. 

She stated, that she had never been aware of having anything unusual, and had 
never observed the swelling, until I called her attention to it on my first visit ; when, 
not knowing how short a time she had been married, I suggested to the attendant 
practitioner that there might be pregnancy. She had been long subject to great 
losses of blood at each catamenial period ; and sexual intercourse had given her ex- 
treme pain during the short period of her marriage. 

Soon after 1 first saw her, large fragments of firm, lobulated texture, with thinner 
membranous portions, and of various forms, were passed, and so far as I recollect, 
this continued for several weeks. 



TUMOURS OF THE WALLS OF THE UTERUS. 225 

She gradually recovered, and after some months, all uterine tenderness ceased. 
She became pregnant, and had a healthy child at the usual period. 

Through the kindness of Dr. Walshe, of University College, I have 
seen these portions of broken-down scirrhous growths ; which are pre- 
served in the Museum of that establishment. 

This is an exceedingly rare termination, and only one case followed 
by a similar result has fallen under my notice. The patient to whom 
I allude, a young unmarried woman of 21 years of age, was under 
my care at Guy's Hospital, and for a very large growth, believed to 
be uterine, had at intervals for nearly eight months, during which she 
continued an in-patient, taken iodine. On going out of the Hospital, 
the tumour was lessening, and she imprudently increased the dose of 
the tincture, and used, by inunction, a very large quantity of the iodine 
ointment. 

On visiting her, T found she had been nearly poisoned by the drug ; 
she was exceedingly collapsed; the pulse scarcely perceptible, and the 
surface bedewed with cold perspiration : she seemed thoroughly sali- 
vated, and for several days had scarcely ceased to vomit. I was told, 
that on first reaching home the tumour was so much less, and so much 
softer, that she determined at once, and on her own responsibility, to 
adopt the dangerous treatment I have now detailed. Uterine hemor- 
rhage was induced, and, on inspecting the discharge,! found mixed 
with it ^masses of various sizes of broken-down scirrhous growth. 
These continued to be discharged for a length of time, and when I 
took my leave of her, some months afterwards, there was no percep- 
tible enlargement. 

These examples resemble those rare instances where spontaneous 
gangrene of the surrounding parts has led to the separation and ex- 
pulsion of cancerous growths, and been followed by complete re- 
covery. The testimony of Cline, Home, Steidele, and others, may be 
adduced, as having observed this fortunate accident, and I well recol- 
lect the narration of a case by Mr. Abernethy in his lectures, where 
a similar result was obtained in cancer of the breast, by the truly ha- 
zardous and empirical exhibition of arsenic. 



Case 47. 

large hard tumour of the uterus, with an account of the post-mortem 

appearances. 

Mrs. , aged 44, was married at 36 years of age. but has never been pregnant. 

She enjoyed excellent health, and was remarkably active up to her fortieth year. At 
that time (1827) she first discovered a tumour in the lower part of the abdomen, an 
inch or two above the symphysis pubis, which was supposed to be uterine. For two 
or three years the growth slowly increased, without disturbing her health, or causing 
any marked inconvenience. In November, 1831, I was first requested to visit her; 
and on examination, I found a tumour in the abdomen, about the bulk of the uterus, 
in the sixth month of gestation. It had mounted nearly to the umbilicus, and ap- 
peared to consist of one large, and a second smaller growth ; the latter being placed 
low down, near the left groin; while the former, remarkably bulky, occupied the 
middle and right lateral region of the abdomen. Both were hard, slightly movable, 
and not painful to the touch. The increase of size has been especially manifest 



226 TUMOURS OF THE WALLS OF THE UTERUS. 

only for a few months ; and was particularly attributed to the pressure and excite- 
ment of tightly bandaging the abdomen, a practice professionally recommended. 

The functions of digestion and nutrition were somewhat impaired ; but although 
there was loss of flesh, there was no decided emaciation. The bowels were consti- 
pated ; and a purgative was frequently taken to stimulate the intestinal canal, whose 
functions were mechanically interrupted. The thighs and the legs, but especially 
the ankles, were (Edematous; the respiration was occasionally embarrassed ; and, 
on exertion, there was palpitation of the heart. The urine was scanty ; the pulse 
95 to 100; and there was an unhealthy and partially jaundiced hue about the skin. 
Menstruation (the patient being nearly 44 years of age) was regular and healthy. 

By an internal examination, it was ascertained that the cervix uteri was large, 
and very hard : the anterior lip of the os was knotted, slightly fissured, and painful, 
when touched : the whole internal surface of the vagina was relaxed, and moist from 
muco-purulent discharge. 

The internal and external use of iodine was recommended ; four or five drops of 
the tincture were taken twice or three times daily ; and some of the ointment (about 
as much as a very small nutmeg) was rubbed every night on the os and cervix, as 
well as over the growths externally. The bandage was entirely laid aside : gene- 
rous diet, moderate exercise, and the avoidance of mental and sexual excitement and 
fatigue, were strictly enjoined. Enemata of warm water were to be used occasionally 
as auxiliary to mild aperients. 

It would be uninstructive and tedious to detail minutely the various symptoms and 
progress of the malady. I may, however, remark, that after the iodine had been 
used for six months, with occasional interruptions, the tumours externally had ceased 
to grow ; an opinion in which the patient's friends fully concurred. Exact measure- 
ments had been taken prior to the employment of the remedy, and these were de- 
cisive on this point. The induration and bulk of the cervix were removed, and the 
fissures perfectly free from hardness and pain : there was, also, less leucorrhoeal se- 
cretion ; still, the iodine had seriously impaired her health, and she was much debi- 
litated. She removed to the sea-side; iron and quinine were largely given ; and 
her diet and alimentary canal were carefully attended to. In six months she re- 
turned home with her general health vastly improved. 

From the early part of 1832 till the autumn of 1835, the growth was stationary, 
and free from pain. At this latter period, without any apparent cause, it began again 
to increase; and distressing pain was produced, not only by the distention of the ab- 
dominal parietes, but by the pressure, distention, and traction of internal parts. 
Gradual yet considerable emaciation occurred; but there did not appear to be any 
marked inflammatory symptoms till about six or eight weeks prior to her death ; nor 
was menstruation interrupted. From the combined effects of inflammation and dis- 
tention, her latter sufferings were extreme; for the tumour not only filled much of 
the abdomen, but so completely occupied the pelvis, that it projected far down into 
the vagina. The inflammatory pain had been principally felt a little below, under 
and to the left, of the umbilicus ; and cupping had afforded some relief. Unctuous 
applications, by relieving the stretching and extreme distention, anodyne injections, 
and suppositories, procured some mitigation of her sufferings. The patient expired 
about mid-day on the 20th Nov. 1836. 

The post-mortem examination was made by Dr. Hodgkin (Mr. 
Oldham and myself being present), whose full and very. accurate re- 
port I subjoin. 

The body, generally, was emaciated : no oedema, discoloration, or other remarka- 
ble appearances, were noticed, except as connected with the size of the tumour. 
The abdomen, though so greatly enlarged, wanted the uniform distention of dropsy, 
or even of pregnancy. It was not symmetrical, as to its figure; or uniform, as to its 
resistance. On the right side, on which it rose to the hypochondriac region, it was 
rather nodulous, and firmly resistant. On the left side, on which it did not rise 
quite so high, it was neither nodulous, nor so resistant, but felt almost as if the dis- 
tention was caused by fluid. On turning back the parietes, which were much atten- 
uated, they were found united by feeble and recent adhesions, to the lower part of 



TUMOURS OF THE WALLS OF THE UTERUS. 227 

the tumour; but they were most considerable on the left side. The bond of union, 
which was remarkable, will be presently described. The omentum, which was much 
attenuated, had contracted a firm old adhesion to the tumour above, and to the right 
of the umbilicus. The tumour, at this part, was white or pale, and appeared super- 
ficially semi-cartilaginous; but there was a little recently effused blood coagulated, 
and some small collections of very soft cerebriform matter. The inferior portions of 
the tumour, especially on the left side, were of various shades of livid red and brown, 
very soft, and accompanied with considerable extravasation. The fundus of the uterus 
was raised out of the pelvis, as high as the superior spinous process of the ilium ; 
and was situated about midway between it and the median line, but rather nearer to 
the former. The left Fallopian tube, and the ovary, which was large, broad, and 
flattened, were stretched over the tumour, directly to the left; whilst, on the right, 
the Fallopian tube and ovary, which were much more elongated than the left, were 
also stretched over the tumour, in a somewhat ascending direction, to the right. 
The Fallopian tube must have been eight or ten inches in length : the ovary was 
elongated, and flattened. The round ligament was likewise stretched over the tu- 
mour to the right; but it took first a horizontal, and then a descending direction, 
until it was widely separated from the Fallopian tube. At the upper and posterior 
part, the tumour appeared to have contracted few, if any adhesions, old or recent. 
The tumour, which was situated in the parietes of the uterus, will be described in the 
sequel. There was no appearance of any peritoneal affection, except recent adhe- 
sions about the anterior and lower part of the tumour and the omentum. The ali- 
mentary canal appeared to be healthy; but, although there did not seem to be any 
contraction or induration of the pylorus, the portion of the stomach immediately 
above it showed some tendency to be dilated into a pouch. The mesenteric glands 
were small, and appeared to be quite healthy. The liver also appeared to be healthy, 
but small. The spleen was rather laro-e. 

The character of the recent adhesions between the tumour and the parietes, the 
deposit in the omentum, and the structure of the tumour itself, deserve particular 
description. 

On separating the recently-adhering parietes, it was evident that the material in- 
terposed between the two surfaces of peritoneum was not ordinary coagulable lymph, 
but a soft white cerebriform matter, somewhat like stationers' paste, intermixed with 
spots of extravasated blood of various sizes. On carefully separating further por- 
tions of the attached peritoneal surfaces, it became evident that the soft cerebriform 
matter was not irregularly effused upon the inflamed surface of the peritoneum, but 
that it was collected into circumscribed depositions of very various sizes, but having 
almost universally a rounded but very compressed form: the flatness evidently de- 
pending upon compression between the two opposed surfaces of serous membrane, 
and a circumscribed rounded figure, which seemed to depend on the cerebriform 
matter, not blending with the general secretion of the peritoneum, but rather re- 
maining as a drop of oil would do upon a wetted surface. It likewise appeared, that 
on the surface there was an extremely tender pellicle; which rendered it possible 
to move the soft deposits without breaking them, although their form might be 
changed. A very slight force, however, produced rupture; when the contained ma- 
terial escaped, as a grumous amorphous mass. They might, in fact, be compared to 
little yolks of egg separated from the white, except that their form was more flattened, 
and the inclosing pellicle comparatively more tender. These little collections of 
cerebriform matter possessed different degrees of translucence. Some presented a uni- 
form milkiness; others were spotted with points of extravasated blood ; and in some 
the spot of extravasated blood formed a defined rounded body, which appeared just 
as distinct from the white cerebriform matter as this did from the surrounding tex- 
ture or secretion. These appearances were most beautifully seen on the omentum, 
which was thin and delicate, and, with the exception of these appearances, and the 
old adhesions before mentioned, retained a perfectly healthy character. On the 
omentum, some of these little circumscribed deposits of cerebriform matter might 
be seen scarcely so large as pins 1 heads, whilst others were nearly as large as a 
shilling. The smaller deposits appeared to take their origin very near, or in the 
course of the minute blood-vessels. A little below, under, and to the left of the um- 
bilicus, where the recent inflammation had been most intense, the parietes of the 
cyst were so softened, that, in some parts, the defined limits between the substance 



228 TUMOURS OF THE WALLS OF THE UTERUS. 

of the tumour and the productions of the serous surface were lost ; the fingers pass- 
ing into a mass of the consistence of softened brain, and intermixed with extravasated 
blood. In removing the tumour from the body, some portions of this softened part of 
it were detached, partly by laceration, and partly by the knife. The tumour weighed 
about twenty-five pounds. It was evidently lodged in the substance of the uterus; 
but its fundus and its angles, and the commencement of the Fallopian tubes, and the 
attachment of the round ligaments, though carried out of their natural situation to 
that already mentioned, did not appear to have undergone any distention or derange- 
ment of their relative position, as respects each other. The whole fundus was a 
little enlarged. A section was made through the tumour, so as to divide the fundus 
into two lateral portions : it was carried towards the os, but so as to leave the whole, 
or the greater part of the os, with the left hand-portion. This, which appeared 
to be the best section for showing the state of the uterus, left more than three- 
quarters of the entire bulk on the right side. As it passed through the hardest, and 
also the softest parts of the mass, it afforded views of the varieties of texture which 
it presented. It was evident that this extraordinary enlargement was occasioned by 
the formation of tubercles, having the cystiform arrangement developed in the sub- 
stance of the parietes of the uterus. The greater part of it consisted of one very 
large, and several smaller tubercles, of scirrhous hardness, and of a nearly dead 
milk-white colour, developed in the posterior and right lateral parts of its parietes. 
Within this mass of hard tubercles, but almost in contact with the internal surface 
of the uterus, was a mass, which appeared to be nearly spherical, about four inches 
in diameter, of a deep brick-red, but not uniform colour. It was of fleshy softness, 
and distinctly possessed the cystiform arrangement. The subordinate portions were 
more loosely connected among themselves than in other parts of the solid mass. The 
state of distention of the cavity of the uterus may be inferred from the situation of 
the fundus, which was seven or eight inches from the os. Its internal surface was 
extremely uneven and irregular, from the projections of numerous nodulous, but break- 
ing-down fungoid tumours, of about the size of a chestnut or walnut. They were 
bathed with an offensive dark, sanious fluid. Though the anterior parietes were also 
the seat of adventitious productions of a similar structure, their thickness was 
scarcely, in any part, increased to more than about two inches. There was a great 
variety in the consistence of the,adventitious growths in this part. One well-defined 
tubercle, of the size of a cob-nut, was of a dead milk-white colour, and of scirrhous 
hardness: more had the softness of cerebriform matter, and were variously coloured 
by imperfect organization and extravasation; whilst some possessed the softness and 
transparency of gum or gelatinous cancer. Some of these, notwithstanding their 
great tenderness, distinctly exhibited the form of a reflected membrane, with ex- 
tremely minute and delicate vascularity. The inflammation at the anterior and 
posterior part of the mass appeared to be connected with the breaking down of the 
adventitious structure, including those in the anterior parietes, those projecting in 
the interior of the uterus, and the large sanguineous mass occupying a part of the 
right side. 

CD 

Here, by the use of the iodine, four years, at least, were added to 
the life of the individual, with an almost entire exemption from the 
sufferings previously attendant on the malady: and, had it not been 
for the immense bulk and weight of the tumour (25 lbs.), it is proba- 
ble that a still further period would have elapsed, without the occur- 
rence of that malignant cachexia by which she was eventually' de- 
stroyed. In the growth itself, the morbid changes were such as I 
have already described. There were inflammation, softening, and un- 
healthy suppuration. Nor can it excite surprise, that life should have 
been destroyed by such a complication of ills. I would, however, 
urge the importance of deliberation before the employment of the re- 
medy. In cases, where, after remaining almost, or entirely, station- 
ary for months or years, the tumour has begun suddenly to grow, and 
the patient's health is not materially impaired, the external and inter- 



TUMOURS OP THE WALLS OF THE UTERUS. 229 

nal use of the iodine may be strongly recommended ; but in those 
unfortunate instances, where the growth has been long neglected, and 
where the constitutional powers are beginning to fail before the remedy 
has been suggested, its employment will be injudicious, the strength of 
the patient will be further impaired, and it is not unlikely that the fatal 
result may be accelerated. These cautionary observations are limited 
to the hard tumours of the walls of the uterus : they do not refer to 
similar deposits in the os and cervix. 



Case 48. 
sub-mucous tumour of the uterus ; terminating fatally by hemorrhage. 

Several years ago I attended Mrs. , for profuse menstruation ; which was 

invariably followed, after a few days, by discharges of blood — a fact satisfactorily 
proved by the coagulation of the fluid. 

In 1832, when Mrs. first came under my care, she was 39 years of age, and 

had borne five children, four of whom were living and healthy. The usual treatment 
was adopted — the recumbent posture, the local application of cold, refrigerants, 
opium and the acetate of lead, and a mild yet nutritious diet. The secale cornutum 
was occasionally used ; but disadvantageously, as the uterine pain and the hemor- 
rhage were always increased by it. Several times the bleeding was so considerable 
as to require plugging of the vagina. 

In 1834, 5, and 6, she was not often under my care, the menstruation and the 
hemorrhage being rarely excessive. In January, 1837, I examined the womb inter- 
nally, and distinctly ascertained that the os was open, and that a tumour existed in 
the uterine cavity. A year and a half before, I had found the os healthy ; and al- 
though, by balancing the uterus, I was sensible of its increase in bulk, I could not 
then make out any distinct growth. It was now sufficiently evident how large the 
organ had become, as I could distinctly feel it above the pelvic brim ; and on par- 
tially introducing my hand into the vagina, I could, by my forefinger, touch the 
tumour. 

I remarked that the growth was smooth and broad on its surface, not very hard ; 
that it was painful on touch ; and that it was not pediculated. This examination 
was not repeated, as she complained much of the pain and uneasiness it produced, 
and it was also followed by alarming hemorrhage. 

The remedies already mentioned were ao-ain resorted to ; and, at the snoro-estion of 
another physician, the secale was repeated ; but it produced severe spasmodic pain, 
and a return of the bleeding. 

During the summer of 1837, I was informed she had frequent recurrence of he- 
morrhage; and there was always more or less uterine pain and uneasiness. On one 
occasion, I was particularly struck with her altered appearance ; the pallor of surface 
and general anaemia, being extreme. 

Late in September, 1837, I was hastily summoned, and found her nearly dead. 
Brandy, and plugging the vagina, stayed the fatal result for two days ; but at the 
expiration of that period, after vomiting for some hours everything which was swal- 
lowed, she sunk. 



SECTIO CADAVERIS, 

By Mr. Henry Oldham, twenty-jive hours after death. 

The body was but little wasted, the mammas alone appearing shrunk. The abdo- 
men only was permitted to be inspected. A layer of fat, about half an inch in thick- 
ness, covered the abdominal muscles, which appeared paler than natural. The liver 
was flabby and pale. The gall-bladder contained three gall-stones, with some in- 
spissated bile ; and its tunics were thickened. 



230 TUMOURS OF THE WALLS OF THE UTERUS. 

The stomach, intestines, and liver, were pale and exsanguine, but otherwise 
healthy. 

The uterus was discovered nearly filling the pelvic cavity, projecting about an inch, 
above the brim, and enlarged to about its size under a three months' gestation. Its 
surface was not uneven ; and the peritoneum covering it, retained its natural appear- 
ance. The uterus, with its appendages, were removed. 

On making a section of the anterior wall of the uterus to expose its cavity, the 
paries on the right side appeared considerably hypertrophied, gradually thinning as 
it approached the fundus. The progress of the section was obstructed, about the 
entrance of the right Fallopian tube, by an oval body about the size of an orange, de- 
veloped in the substance of the uterus ; carrying the mucous membrane before it, 
filling and distending the cavity of the uterus, and closely embraced by the uterine 
parietes. On the left side, another tumour, about the same size, was seen ; which 
projected laterally outwards, increasing the bulk of the uterus in that direction. It 
also served to distend the cavity of the uterus, projecting inwards, so as nearly to 
touch the apex of the former tumour ; — the mucous lining, however, passing up be- 
tween them, leaving a passage, as it seemed, to the left Fallopian tube. 

The cavity of the uterus, by these tumours, was made very irregular and exten- 
sive ; and the mucous lining, being reflected from one tumour to the other, covered 
a large space. This last was vascular throughout; but over the surface of the tu- 
mour growing from the fundus, it appeared particularly red, and a web of delicate 
vessels was detached from this part. A recently-formed coagulum, too, was seen ac 
its apex. 

The os uteri was dilated and smooth. The cervix was enlarged ; its structure 
more than usually apparent; and its crypts distended with thick mucus. 

The ovaries appeared preternaturaily full. In the right were found two cysts, 
large enough to inclose a common nut, filled with pellucid fluid. The left contained 
a cyst about the same size. 

The larger and more vascular tumour was laid open, and examined, Before it was 
divided, it felt elastic, appearing about the consistence of steatoma. When inspected, 
it showed distinctly the cystiform character ; one cyst being particularly observable. 
This contained a yellow substance, of the colour and consistence of fat, which was 
but feebly adherent to the containing cyst. 

Case 49. 
sub-mucous tumour of the uterus, terminating fatally by hemorrhage. 

March 25, 1830. Mrs. H , aged 38, is the mother of five children ; the last 

born four years since. She lives in a confined, unhealthy court, in Spitalfields; her 
aspect is cachectic ; and emaciation has been going on for some time. She states, 
that for the last two years she has menstruated profusely, and has had large dis- 
charges in the intervals ; these latter always coagulating. 

She was ordered to use the zinc and alum injection ; to take infusion of roses, with 
acid and nitre ; to continue in the recumbent posture ; and to abstain from sexual in- 
tercourse. 

June 25. Has still profuse bleedings occasionally : employs the remedies care- 
fully — digitalis, nitre, superacetate of lead, and occasional tonics. The latter, and 
the astringent injections, increase the pain and hemorrhage. 

The recumbent posture, cold, mild diet, and sexual abstinence, diminish the dis- 
charge. 

July 1. Bleeding has been excessive. On examining, I find the lower anterior 
part of the uterus greatly enlarged ; the os widely open, easily admitting the fore- 
finger : and a tumour, round, hard, and painful to the touch, may be distinctly per- 
ceived. The urine and faeces are passed with difficulty. As pain and hemorrhage 
were produced by this investigation, it was not repeated. 

Twice, between this and July 25, the vagina was plugged. On this latter day, 
after large bleeding, she died. 

The body generally, and especially the abdomen, was emaciated ; and a large and 
hard uterus could be distinctly felt above the pubes. 

The walls of this organ being divided, a hard, scirrhous tumour, about the bulk of 



TUMOURS OF THE WALLS OF THE UTERUS. 231 

a very large orange, was found imbedded in the walls, and encroaching on the ca- 
vity. There was a thickened and highly vascular covering of the mucous mem- 
brane over the growth internally; nor was there any of the muscular tissue between 
the tumour and its mucous investment. 

There were in other parts several smaller scirrhous growths ; and the viscus was 
nearly as large as at the fifth month. 

Case 50. 

For this interesting case I am indebted to Dr. Marshall Hall. It 
furnishes another example of pregnancy complicated with hard or 
scirrhous tumours of the uterus, occurring, too, at rather a late period 
of life. It is also worthy of remark, that, after parturition, the tu- 
mours inflamed, and one of them suppurated, thus leading to a fatal 
issue. These facts I have especially noticed in a former part of this 
work. There can be little, if any doubt, that the hemorrhage in this 
instance was dependent on the diseased structures. Dr. Hall "is de- 
cidedly of opinion, from what he has observed, that tumours thus im- 
bedded in the structure of the uterus excite hemorrhage, and espe- 
cially in the subjoined case." 

Mrs. T. C , aged 43 or 44, after having been subject to profuse menorrhagia, 

for twelve vears of unfruitful marriage, at length became pregnant. 

During the course of her pregnancy, tumours were distinctly felt in several parts 
of the parietes of the distended uterus ; and one was so superficial, that a medical 
gentleman mistook it for hernia. 

Parturition was pretty well accomplished ; but the tumours inflamed, puerperal 
peritonitis occurred, and the patient died. 

On a post-mortem examination, several tumours were found inflamed, and one of 
them suppurated. — The uterus was only partially contracted. 

Case 51. 

The following particulars were furnished by Mr. Lever, with whom 
I saw the patient during life. An inspection after death would, I 
doubt not, have corroborated the opinion we expressed, that the he- 
morrhage was dependent on the uterine tumour. 

Mrs. A. D , aged 54, residing near Finsbury Market, was married at 23, and 

is the mother of only one child ; never having had a miscarriage. Three years 
since, her menstrual periods became prolonged; being always attended by large 
discharges of coagula, and constant severe pain in the uterine region. For two 
years, these symptoms were entirely disregarded ; but a twelvemonth prior to this 
time (1834) she employed astringent injections, and astringent medicines were 
given. For six months she had but slight menorrhagic losses, when alarming uterine 
hemorrhage again occurred. Under the advice of another practitioner, who told her 
friends that she had malignant tumour of the uterus, she employed astringents and 
tonics, deriving some relief. The secale cornutum was used ; but greater pain and 
more excessive bleeding invariably succeeded its exhibition. Mr. Lever saw her 
soon afterwards, and quickly recognised the results of excessive hemorrhage. On 
examining internally, the os was soft and patulous: anteriorly, the neck was short- 
ened ; and through it could be felt something large and hard, occupying the uterine 
cavity. That it did not grow from the cervix was evident, as this "latter part could 
be freely moved upon the tumour.— Dr. Ashwell also examined and confirmed the 
above statement. 

In a few more weeks, a large bleeding occurred, from which she never rallied. 
(No examination could be obtained.) 



232 TUMOURS OF THE WALLS OF THE UTERUS. 



Case 52. 

In May, 1837, 1 visited Mrs. ,aged 41 ; a patient of Mr. Dodd in Wilderness 

Row. She had never borne children, although she had been long married. She 
had lost much blood from the uterus ; not only at the catamenial periods, but at other 
times ; and she was now confined entirely to bed. Her face, indeed her whole sur- 
face, was pallid, and her strength was seriously impaired. She suffered much ute- 
rine pain, and frequently took opium to procure sleep. 

On examining, 1 found the os patulous, and the cervix enlarged and (edematous. 
I could distinctly feel, and touch, a large growth occupying the lower part of the 
uterine cavity. At first, I thought it might be polypus; but on carrying my hand 
partially into the vagina, my finger passed over a large tumour, situated as above, 
with a broad, smooth surface, and evidently not pediculated. Pressure produced 
pain : and a probe gently pushed against the growth, made her cry out. A good 
deal of blood, which coagulated firmly, was lost after this investigation. Astringent 
injections into the vagina and rectum, the recumbent posture, abstinence from sex- 
ual intercourse, and a mild but nutritious diet, with the vegetable tonics, were en- 
joined. All idea of any operation was abandoned. 

It need not be observed in how many particulars this disease dif- 
fered from uterine polypus. 

Case 53. 
sub-mucous tumour of the uterus', post-mortem appearances. 

In July, 1835, I was consulted by Miss , set. 48, on account of repeated 

uterine bleedings. Believing that at her age such occurrences were not uncommon, 
she had hitherto entirely disregarded them ; and even now would not have sought 
any opinion, had it not been for a tumour she had lately discovered in the right hy- 
pogastric region. Her aspect was cachectic, and the dark leaden hue and deep 
lines of her countenance, plainly indicated that there was serious disease. The 
breathing was embarrassed ; the heart palpitated, and the pulse became rapid and 
fluttering on the slightest effort. The prolabia and conjunctivas were bloodless. The 
abdomen was distended by flatus, and the legs and ankles were swollen and cedema- 
tous. She had scarcely any appetite; her digestive power was nearly destroyed; 
and the urine was scanty, high-coloured, and albuminous. 

Such was her state on my first visit; but as I was allowed to examine only very 
imperfectly, the condition of the tumour and the uterus were not ascertained. 

Some days afterwards an alarming hemorrhage occurred ; and on its cessation, I 
found a tumour in the fundus of the uterus, exceedingly hard, and apparently of the 
size of a large orange. The os and cervix were quite healthy, although the former 
was unusually patulous. Menstruation had not ceased, but it recurred at irregular 
intervals. 

It would be tedious and uninstructive to detail the various remedies employed du- 
ring the four years prior to her death : but! may say, as there was scarcely ever any 
pain in the tumour, and as her circumstances permitted every indulgence, her life 
was not an unhappy one. Frequently, however, the bleedings were so profuse as to 
threaten a fatal result : and on several occasions a long time elapsed after they had 
ceased before she could be lifted from the bed to the sofa. 

Alum in various doses, the alum bath, and a seton across the hypogastric region, 
appeared for a time to do much good. Still it was apparent, especially during the 
last six months of her life, that nothing really beneficial could be done ; and afier 
several minor hemorrhages, she sunk on the 30th of May, 1839, never having rallied 
from a large bleeding of the day before. 

The body was examined by Mr. Henry Oldham of Guy's Hospital, 
whose report I annex. 



TUMOURS OF THE WALLS OF THE UTERUS. 233 

The abdomen only was inspected. 

The incision was made through a layer of fat, about half an inch thick; and the 
abdominal muscles, which were well developed, appealed paler and softer than usual. 
There was no appreciable morbid change in any of the viscera, excepting the uterus 
and the ovaries, only ihey were universally pale, aud unctuous to the touch. 

The uterus was distinguished, occupying a large space in the pelvic cavity, and 
its upper part surmoun'ed the brim. It was removed, with its appendages, for more 
careful examination. It presented externally an uneven globular appearance, in size 
like a very large lemon. The right lateral portion was much larger than the corre- 
sponding left part, so that when a section was made in the proper mesian line, two- 
thirds of the entire growth were found on the right side. On dividing the uterus to 
expose its cavity, the greater part of the tumour was found developed on the anterior 
wall, so that about two and a half inches of hard, solid material was cut through, be- 
fore the cavity could be exposed. With the exception of one isolated portion, about 
the size of a nutmeg, which was a softer tubercle within a distinct cyst, the remainder 
of the tumour consisted of a hardened structure of well-marked linear arrangpment, 
through the substance of which several vessels of the size of a crow-quill were seen, 
having open mouths on their truncated extremities. It was much regretted that time 
would not permit a more careful dissection of these vessels, and that we were pre- 
cluded from injecting the tumour from the spermatic arteries. In other respects 
than this vascular character, the tumour resembled the ordinary scirrhus or hard 
tumour of the walls of the uterus. The cavity had not been encroached upon by the 
surrounding growth. The mucous membrane was more rough than usual, but in 
general healthy, and the cavity was filled with acoaguium. The left Fallopian tube 
was pervious; the opening to the right, however, from the angle of the uterus, was 
obliterated by the intervening solid mass. 

The ovaries were much corrugated, but of good size, their proper tunics being 
thicker than usual. The left had a superficial cyst, sufficiently large to inclose a com- 
mon nut, filled with a clear transparent serum, and its lining membrane was beauti- 
fully injected with minute blood-vessels. 

The peritoneal covering of the uterus and appendages was shining and healthy. 

[The occurrence of fibrous tumours of the uterus which the author 
seems to consider carcinomatous in their character, is by no means rare 
in the United States ; very many of the female subjects which are 
brought into the dissecting rooms of the University presenting in- 
stances of the disease ; and what is curious they do not seem to have 
produced any symptoms during life which could' be referred to them, 
for the history of many of the subjects could be traced without much 
difficulty. I once examined a lady, a patient of the late Dr. Dewees, 
who was troubled with an obstinate prolapsus uteri. She died of re- 
mitting fever, and the examination was made to ascertain the cause of 
the obstinacy of the case. A large fibrous tumour occupied the fundus 
of the uterus, and by its weight produced the displacement. In this 
case, as in all others which I have seen, the tumour was not connected 
with the uterus save by small filaments; and its cyst being opened, it 
could readily be turned otit with the fingers. This is not the case with 
true scirrhus. — Am. Ed.] 



CHAPTER III. 

ON PREMATURE LABOUR IN PREGNANCY, COMPLICATED WITH 

ORGANIC DISEASES. 

There is, perhaps, no part of the work to which this important sub- 
ject could be appended with more propriety, than to the section com- 
prising the affections of the uterine parietes. I shall, therefore, place 
before my readers the history and treatment of pregnancy and parturi- 
tion, complicated with such uterine and pelvic tumours, and such or- 
ganic affections of the vagina and external genitals, as justify and en- 
courage the induction of premature labour, proposed by myself, in a 
paper published in the Guy's Hospital Reports several years since. I 
have previously observed, that to some, who have not noticed the 
course and results of these diseases, it may appear singular, that con- 
ception should occur at all: but it must be remembered, that they in- 
terfere only slightly with the general health, and that menstruation is 
almost as regularly performed, as when the uterus is not structurally 
diseased. It is also remarkable, that pregnancy not unfrequently takes 
place, when these tumours or other malignant diseases have existed for 
years, and when that period has arrived, at which the conceptive sus- 
ceptibility might naturally be supposed to have nearly ceased. It is 
almost superfluous to remark, that patients becoming pregnant in such 
a condition of the viscus, are exposed to the most imminent danger. 
The tumours soften during the latter months ; the increased supply of 
blood leads to inflammation ; unhealthy suppuration is established in 
them ; and death occurs soon after parturition. This, in few words, is 
their pathological history : and, if it be duly considered, the profession 
will probably conclude, that a better and more certain plan of treat- 
ment will be, the induction of premature labour, before that period when 
the tumours shall be subjected to pressure and contusion, from the firm, 
large, and unyielding gravid uterus. 

To establish its propriety, it is necessary to prove two or three posi- 
tions ; amongst which, I may especially mention the following. 

1st. That when death occurs, after a labo/ur so complicated, the re- 
sult is only slightly, if at all, referable to the uterus, which rarely sus- 
tains any serious mischief; but is mainly produced by inflammation, 
softening, and unhealthy suppuration in the growth itself; — these pa- 
thological changes leading, in some instances, to rapid sinking ; while 
in others, the powers of the system having been less impaired, death 
ensues in a few days, from the constitutional collapse, induced by the 
protraction and difficulty of parturition, and by the contusion and in- 
jury done to the tumour and other soft parts. And, 2dly, That pre- 



ON PREMATURE LABOUR IN PREGNANCY, ETC. 235 

mature parturition, artificially induced, rarely occasions constitutional 
mischief, is easily accomplished, and affords the best, and in many in- 
stances, the only chance of safe result to the mother. 

1. It must be allowed, that pregnancy complicated with tumours of 
the uterus itself, of the ovary, or with those of a purely adventitious 
kind, growing either from the abdominal or pelvic cavities, gives rise, 
in labour, to difficulties of the worst kind. In parturition, where the 
danger is produced by the narrowness or deformity of the pelvic brim, 
cavity, or outlet, the extent of the obstacle can generally be accurately 
ascertained. If the abbreviation be within certain limits, the forceps 
is relied on : if, on the contrary, the encroachment on the pelvic spaces 
be still greater, the perforator is resorted to. In either alternative, if 
the assistance has not been too long delayed, the probability is, that a 
fortunate termination will be secured. It is not so, how T ever, where 
tumours obstruct the birth of the child : here the extent of the difficultv 
can rarely be correctly appreciated ; and even where the head may 
have ultimately overcome the obstacle, and the uterus have escaped un- 
injured, the same assurance cannot be entertained of the morbid growth. 
The safety of a patient, having such a tumour, might have been only 
barely secured by a freedom from even the commonest excitement, 
w r hereby its natural supply of blood would have been, perhaps, dimi- 
nished ; but now, the growth has not only shared in the sympathetic 
excitement of pregnancy, but has also sustained severe pressure and 
contusion from the unyielding gravid uterus, and has participated for 
months in an increased supply of blood. Thus is the condition of the 
tumour rendered worse ; and if such changes had occurred, indepen- 
dently of gestation, it would excite no surprise to find the system pain- 
fully sympathising ; but so far from being surprised, we must antici- 
pate after the protracted and exhausting struggle of labour, that an 
unfavourable result will frequently occur. 

Professional attention has not hitherto been sufficiently directed to 
the agency of the tumour itself, in the production of the fatal event. 
Of course, it has not been overlooked, that it is the cause of the diffi- 
culty in parturition ; but it seems to have been almost forgotten, how 
well women gradually recover from protracted, difficult, and instru- 
mental labours, where there is no tumour, or adventitious growth of 
large size. A due estimation of this fact would, I believe, ere this, 
have led to the practice I propose : a careful reader of the narratives 
of labours thus complicated, and of the rapid dissolution following 
them, will discern, to a certain extent, a parallel as to the fatal sink- 
ing, between them and labours where the use of instruments has been 
too long deferred. I have several times witnessed the loss of life in a 
few hours after delivery by the perforator, where sixty or seventy 
hours had been improperly allowed to elapse before its employment ; 
the impression on the system being very similar in both instances. 

In all the fatal instances of pregnancy complicated with tumour 
which I have seen, and where I have had the opportunity of examin- 
ing the parts after death, the uterus itself has been healthy, or very 
nearly so ; and, in the majority of those recorded, this viscus is re- 
ported to have been either in a natural state, or free from disease. Dr. 



236 ON PREMATURE LABOUR IN PREGNANCY, 

Merriman's Papers (First Part of Vol. X. of Medico-Chinirgical Trans- 
actions) also corroborate this statement ; and in an able account of a 
post-mortem inspection of a very interesting complication of this kind, 
by Mr. Hewlett, in the Seventeenth Volume of the same work, it is 
said " to the front, and resting on the tumour, was the uterus, free from 
disease." These facts will probably satisfactorily prove the first part 
of my position ; viz., that when death occurs in labours thus compli- 
cated, the result is only slightly, if at all referable to lesion of the ute- 
rus. The symptoms during life, and the inspections after death, will 
lead to the conclusion, expressed in the former part of these observa- 
tions — that the unfavourable termination is mainly referable to inflam- 
mation, softening, and unhealthy suppuration in the growths themselves. 
In several of the appended Cases, this will be clearly evident : nor 
is it possible to pursue their histories, and examine the preparations, 
without arriving at this opinion. The Case occurring in Miriam's 
Ward is, in this respect, peculiarly instructive. The patient, after a 
good labour, not followed by any distressing uterine symptoms, or by 
any approach to collapse, suffered most severely from acute pain and 
enlargement of the tumour, accompanied by an anxiety of counte- 
nance, and a hardness and rapidity of pulse, indicative of alarming 
mischief, and ushering in a train of constitutional symptoms, almost if 
not entirely referable to the morbid growth ; and from which she was 
recovered with great risk and difficulty. 

The cases already alluded to in the Medico-Chirurgical Transac- 
tions confirm these views. Nor is it difficult to believe, if these re- 
marks as to the changes induced by the pressure of the uterus and the 
effects of labour on growths characterized only by their bulk and in- 
duration, be true, that, in malignant tumours, whether of the uterus, 
ovary, or other parts, the danger must be imminent indeed, fully and 
satisfactorily accounting for the rapid extinction of life. If, as in Case 
57, where the tumour was only pressed and contused between the ute- 
rus and the abdominal parietes and diaphragm, the alarming symp- 
toms, endangering the patient's life, were entirely attributable to the 
tumour; we may, without any hesitation, acquiesce in the following 
opinion of Dr. Merriman, viz., " That, upon the whole, the evidence 
we at present possess is most in favour of opening the tumours ; for, of 
the nine women out of eighteen, who recovered more or less perfectly, 
five appear to owe their safety to this operation ; and of the three chil- 
dren born alive, or supposed to be so, two were preserved by the same 
means." 'ihese inferences confirm the views I have already express- 
ed — that where the tumours can be preserved from contusion and its 
consequences, a favourable result may be hoped for. 

2. I shall now proceed to show, that premature parturition, artificial- 
ly induced, rare/ y occasions constitutional mischief; is easily accomplish- 
ed ; and affords the best, and certainly in many instances, the only chance 
of a safe result to the mother. 

It may not, perhaps, be totally out of place, to narrate the cases 
which first prompted me to think of and recommend this practice. 

Some years ago, I was requested to see a poor woman advanced 
to the seventh month of pregnancy, who was suffering from accidental 



COMPLICATED WITH ORGANIC DISEASES. 237 

hemorrhage. Her former labours, and especially the last, had been 
difficult and dangerous, owing to what was supposed to be a fleshy 
tumour situated between the rectum and vagina. On examination, I 
found a firm, smooth and unfluctuating growth, about the size of a very 
large orange, occupying the hollow of the sacrum, and filling up the 
vagina. With difficulty I reached the os, and, in my anxiety to as- 
certain the presentation, my finger penetrated further and more forcibly 
than it ought to have done, into the cervix. I waited some hours; 
but as the pain and the discharge had entirely ceased, I returned home, 
somewhat embarrassed as to the best mode of procedure. In former 
pregnancies the growth had been pushed above the brim ; but at those 
periods it was neither so large nor so immovable as at the present 
time. I determined, if the labour proceeded, that I would again at- 
tempt this practice. A day elapsed without my having been sent for: 
and I was greatly astonished, at the next visit, to hear, that twenty- 
four hours after the examination, the pains had returned, the mem- 
branes had quickly ruptured, and a dead child, about six months and 
a half, or seven months old, had been easily expelled : thus, uninten- 
tionally, I had separated the membranes sufficiently to induce prema- 
ture labour, the best remedy for the complication. The recovery was 
good. Soon afterwards this patient removed from the neighbourhood 
of the Tower, and I entirely lost sight of her. 

Late in the year 1834, in consultation with Mr. Callaway and Mr. 
Gowar, I saw a patient whose history resembles the case already 
stated. Mrs. -is nearly forty years of age, and, in her last con- 
finement, her safety was endangered by a tumour filling up a large por- 
tion of the vagina, which obstructed the descent of the head. After 
some ineffectual attempts to dislodge it by the medical attendant, Mr. 
Gowar was called in ; and placing the patient on her hands and knees 
(thus inverting the pelvis), he succeeded, after considerable effort, in 
getting the tumour above the brim. The birth was now easily accom- 
plished, and the recovery was natural. The growth had increased in 
the interval between the last and the present pregnancy ; and as she 
was approaching the sixth month, it was necessary to determine what 
was to be done. On examination, I was struck with the size and firm 
attachment of the tumour ; which so filled up the vagina, as to make 
it a matter of difficulty to reach the os uteri : this, after some little time, 
I accomplished ; and satisfied myself that the neck was shortened, and 
that she was probably correct in her calculation. This examination 
was repeated by the gentlemen already mentioned, and we recom- 
mended, that premature labour should be induced a little before the 
seventh month. On inquiring about this lady after a few days, I was 
informed, that we had, although unintentionally, separated the mem- 
branes sufficiently to induce expulsive action of the uterus, and that a 
six months' child had been expelled. The mother recovered well. 

A perusal of obstetric communications on the subject will remove 
all reasonable doubt as to the general safety of this method of proce- 
dure. I have induced premature labour in a number of cases; and 
rarely has there been sufficient excitement of system to cause the 
slightest anxiety. I cannot therefore concur in the opinion of the late 
16 



238 °N PREMATURE LABOUR IN PREGNANCY, 

Dr. Gooch, when he says, " that foreigners are exceedingly afraid of 
this operation : and certain it is, that great disturbance of the nervous 
system is produced by it ; severe rigors, rapid pulse, and delirium, are 
the occasional consequences." It is due, however, to Dr. Gooch, 
whose name cannot be mentioned without admiration, to say, that he 
regarded these symptoms as proceeding from nervous irritation, and 
scarcely continuing long enough to produce any serious results ; some- 
times ceasing so soon as the pains commenced ; and, if not then, after 
the uterus had been emptied. It may also be remarked, that, in the nu- 
merous instances recorded, there is scarcely an allusion to any risk or 
injury to the mother. If, indeed, we reflect for a moment on the for- 
midable dangers avoided by the operation, where there is narrowing 
and deformity of the pelvis, it will readily be allowed, that the ills of 
" nervous irritation" may well be endured, to prevent the difficult, pro- 
tracted, and dangerous struggle which cannot fail to attend parturition 
under such unfavourable conditions. 

The history of this practice is curious: it was first successfully 
adopted by Dr. Macauly, in 1756 ; the idea having probably been sug- 
gested by his observing, that women with narrow pelves, if labour 
occurred much before the full period, expelled the child with com- 
parative facility. Like other innovations on established customs, it 
received, at first, the advantage of a decided and almost superstitious 
opposition. Denman relates, that in the same year in which it was 
first performed, an assembly was convened of the obstetric practi- 
tioners of London, and a discussion was gravely prosecuted, as to its 
morality, safety and utility. Happily, all these questions are now set 
at rest, by the decided advantages accruing from its performance. It 
may, then, be assumed, that whether labour is induced, either by at 
once rupturing the membranes, or by separating them from the inner 
surface of the cervix, safety to the mother will be the general result. 
Further than this, Dr. Francis Ramsbotham has, in many instances, 
successfully induced the same result by the administration of the ergot : 
and even here, although a drug of controverted powers (in which, 
however, I place great confidence) was employed, the mother was 
equally free from all injurious consequences. Dr. Ramsbotham says : 
" All these patients (in whom premature labour has been thus induced) 
recovered, as well as after the most common labour at the full period ; 
and in none of the cases was there the least indication of a disposition 
in the uterus to assume its contractile function previously to the exhi- 
bition of the medicine. I could recite many similar instances, equally 
demonstrative of the power of the drug, and proving its harmlessness, 
at least so far as the mother is concerned." 

I need hardly allude to the statistics of the operation ; but it is 
impossible to notice the circumstantial data connected with this great 
obstetric improvement, without congratulating society on the aug- 
mented safety of the mother, and on the increased number of infants 
preserved by its intervention. Dr. Hamilton, of Edinburgh, affirms, 
that out of twenty-eight cases of premature labour, thus induced, he 
has saved twenty-four children ; and in one patient he performed the 



COMPLICATED WITH ORGANIC DISEASES. 239 

operation in ten different pregnancies. It ought, however, to be re- 
marked, that this is greatly beyond the average amount of success. 

Fortunately, pregnancy complicated with tumour is not of such 
common occurrence as pregnancy with a narrow and deformed pelvis ; 
and consequently, the necessity for the intervention of art has not 
been so urgently pressed upon the attention of professional men. Still, 
if the contingency is more rare, when it does arise it is infinitely more 
dangerous, at least if the tumour be large, and so situated as to ob- 
struct parturition. Seeing, then, how admirably the dangers of the 
former class of difficult labours are evaded by premature parturition, 
I may be allowed to express surprise that this operation has not been 
resorted to in these more formidable complications. I contend, there- 
fore, that this practice is peculiarly applicable to these cases, almost 
independently of any reference to the life of the child. In support of 
this opinion, it may be observed, that there is a vast difference be- 
tween cases of pelvic narrowing and deformity, where there is nothing 
to preclude the safety and desirability of pregnancy but the faulty con- 
formation, and cases of morbid growths or diseased enlargements of 
organs, which render it urgently important, that impregnation should 
not occur ; or, if it have occurred, that it should not so far advance, 
as to call into activity the dormant energy of the tumour. The life 
of a foetus is, under such circumstances, of comparatively little mo- 
ment. 

This chapter would, however, be incomplete, without an attempt to 
explain some of the doubtful circumstances attaching to these ma- 
ladies. I am aware, that, not unfrequently, the full time of pregnancy 
will have been completed before the attention of the practitioner is 
directed to the existence of a large abdominal or recto-vaginal growth : 
here the procedure now recommended will be clearly inapplicable, and 
the judgment and the resources of the accoucheur will soon be in pain- 
ful exercise. He will then have to proceed timidly and uncertainly ; 
ever feeling, in the highest degree, doubtful of success. The size of 
the tumour will also induce hesitation ; and I conceive that the atten- 
dant will be justified in leaving the work to nature, where the growth 
is small or only of moderate dimensions, and where it is not so placed 
as to prevent the advance of the child. Various considerations may 
aid the decision. If the tumour be movable ; if it be so situated, that 
the enlarging and hard uterus has pushed it out of the way, and does 
not make painful pressure upon it ; if it be the first labour so com- 
plicated ; or if it be the second or third, the growth not having in- 
creased during the intervals of the successive pregnancies ; then 
" sequere naturam" should be the guiding precept. If, however, the 
opposites of these circumstances present themselves, it would be un- 
wise to run the risk which a labour to be naturally prosecuted at the 
full time could not fail to induce. Let us take, as an illustration, the 
57th Case, where the patient, having a large ovarian growth, passed 
tolerably well through the labour; but was subsequently placed in im- 
minent danger, by inflammation of the tumour, the constitution being 
implicated to an alarming degree. Here, if pregnancy again oc- 
curred (even if the tumour had not increased, but certainly if it had 



240 ON PREMATURE LABOUR IN PREGNANCY", 

even only slightly grown), I should strongly insist on premature la- 
bour being induced at the seventh month ; thus avoiding the changes 
of a mischievous kind likely to be produced in the tumour during the 
last months of gestation, and certainly evading those greater dangers 
so attendant upon parturition. 

Without presumption, I may be allowed to express an opinion that 
if this practice had been adopted in the interesting cases related by 
Dr. Merriman, a different result might probably have been attained ; 
although, even in hinting this, for the sake of illustrating my argu- 
ments, I am desirous not to be thought to express any other than the 
greatest confidence in the talents and experience of this distinguished 
practitioner.* A careful perusal of the case narrated by Mr. Hewlett, 
will additionally strengthen these views : here, nearly two months 
elapsed between the first parturient indications and actual labour ; and 
during the whole of this period the patient was painfully distressed by 
suffering arising from pressure, exciting inefficient uterine action, and 
obstructing the veins and lymphatics in their important functions. 
These, if I am not mistaken, were precisely the symptoms to have 
been relieved by diminution of uterine bulk: the inspection after death 
rendering it quite clear, that the abdominal and pelvic cavities were 
incapable of affording lodgment to three such bodies as the pregnant 
uterus and the two enlarged ovaries. Let it not be supposed, I am 
insinuating that premature labour, induced when Mr. Hewlett was 
first called, would have protracted the life of this lady for any length- 
ened period, if at all: the malignant disease of both ovaries forbids 
such an opinion. Still, in the absence of positive knowledge of the 
malignancy of tumours (a point difficultly determined when they are 
concealed in cavities), our best treatment consists in preserving such 
growths from excitement, pressure, and contusion. 

These remarks are quite as pertinent to my own cases, and pecu- 
liarly so to the Case No. 56. In this instance, the growths had ex- 
isted, probably for years, before the occurrence of the unexpected and 
unwelcome pregnancy ; and as there was no pain about the uterus till 
the sixth month, it may be assumed, that if the development of its cer- 
vical portion had been prevented by a premature evacuation of the 
uterine contents, the softening, suppuration, and almost gangrenous 
condition of the growths might have been arrested. It is possible, that 
the development of the uterine fibres may be interrupted, and their ac- 
tion almost paralysed, when large tumours are situated directly within 
the parietes of the organ, and abortion, or premature labour, or linger- 
ing and impracticable parturition, may be the result :j nor is it difficult 

* It is evident that premature labour could not have been resorted lo in these 
instances, as Dr. Merriman was not called to any of them till labour had actually 
commenced. 

f A case related by Prefessor Osiander, of Gottingen, and quoted by Dr. Forbes in 
the October number of the British and Foreign Medical Review, corroborates this 
opinion. The patient, 45 years old, scrofulous and unhealthy, had already mis- 
carried twice, but had never given birth to a living child. The labour, after which 
she died in three days, was not interrupted and impeded by the pressure of the tu- 
mours, nor was the pelvic cavity contracted by their presence; but the action of the 
uterus was 80 paralysed, and the expansion of its fibres so entirely prevented, that 



COMPLICATED WITH ORGANIC DISEASES. 241 

to understand, that fatal hemorrhage might be the result of the attach- 
ment of the placenta near, or partially over, one of these growths. 

Another point of importance is, the time when premature labour 
should be brought on. A variety of circumstances will influence the 
decision of this question. If the practitioner enjoys the advantage of 
an early introduction to his patient ; if he possesses tact enough nicely 
to examine the bulk and attachments of the tumour ; and if he has ac- 
curately noted the first attacks of pain in it, and the constitutional 
impression produced by them ; he will not hesitate much as to the pre- 
cise period when to adopt this measure. I should not delay, if there 
were constant pain in or near the growth ; if the respiration were em- 
barrassed ; and if, as a consequence of these conditions, the pulse were 
quick and irritable, the extremities oedematous, and the functions of the 
kidney and skin were partially or greatly interrupted. When such an 
amount of evil exists, or rather before the entire series of these symp- 
toms is complete, the moment has arrived to empty the uterus : and I 
venture this opinion with the more confidence, conceiving that preg- 
nancy will rarely give rise to this amount of mischief till the sixth or 
perhaps nearly the seventh month of gestation ; when, if turning shall 
be required, it may be accomplished with only the usual difficulties and 
hazards. One of the Cases (No. 56) will demonstrate the almost insu- 
perable difficulty of determining whether pregnancy really exists or 
not : and I need scarcely say, that this knowledge is indispensable, be- 
fore the decision as to the employment of this remedy can be arrived 
at. Such extreme obscurity is rare : nor will it invalidate the general 
worth of the measure. 

Thus, whatever may be said to the contrary, pregnancy is not unfre- 
quently complicated with malignant tumours of the uterus itself, of the 
ovary, and with those of a purely adventitious character ; growing 
either from the abdominal or pelvic cavities, and giving rise, in labour, 
to difficulties of the worst kind. 

It can scarcely be necessary to confirm these statements by extended 
reference ; but I may mention the recorded cases of Dr. Merriman, 
numerous others, my own, and Dr. Ferguson's, as clearly proving this 
not unfrequent coincidence. Mr. Hewlett's case, Dr. Merriman's and 
my own, will satisfactorily establish the malignancy of the growths 
themselves. I might enlarge here ; but sufficient testimony has per- 
haps been adduced, to confute an opinion, " that the coincidence of 
conception with a disease of the uterus, already malignant, is exceed- 
ingly rare." 

I propose, then, to evade the dangers of inflammation of the pelvic 
tissues and peritoneum, and of the still more hazardous evils of un- 
healthy softening, suppuration, and ulceration of the tumours them- 
selves, by the simple and safe expedient of premature labour ; a prac- 
tice accidentally suggested to me, and enforced, on reflection, by the 

this celebrated practitioner was compelled to perforate. On a post-mortem examina- 
tion, the whole right side of the abdomen was found occupied by an enormously large 
uterus, beset with hard swellings, like eggs, of a somewhat oval form, and filled with 
a yellow caseiform matter, resembling pus, the liquid parts of which had been ab- 
sorbed. These large tubercles were nine or ten in number. 



242 ON PREMATURE LABOUR IN PREGNANCY, 

fact, that death had frequently occurred where pregnancy was so com- 
plicated under the best known treatment, exclusively of premature la- 
bour artificially or spontaneously induced. Nine out of the eighteen 
cases which fell under the notice of Dr. Merriman terminated fatally ; 
Mr. Hewlett's case was equally unsuccessful ; and three of my own 
patients fell victims to gangrenous inflammation of the tumours, pro- 
duced by their contusion during the process of delivery. Worse re- 
sults could not have followed premature labour ; and I feel confident 
that, had it been induced, several lives might have been saved. It 
may be inquired, whether there was not sufficient mischief done to the 
uterus, in these cases, to insure a fatal event ? Certainly not. In 
most of the cases mentioned by Dr. Merriman, there is no allusion to 
the condition of this viscus ; and when there is, it is stated, with one 
exception only, to have been healthy. In Mr. Hewlett's and my own 
examples, the womb was free from inflammation. I believe these pa- 
tients to have been destroyed, as others will be, where this practice is 
not adopted, by morbid and malignant changes in the tumours them- 
selves ; collapse, and final sinking, having been induced, much in the 
same way as after pressure and strangulation of an intestine, or after 
contusion of the soft parts in difficult labour, where an inspection after 
death commonly brings into view intense inflammation, and sometimes 
gangrene and disintegration. 

A corroboration of the propriety of the measure is furnished by the 
marked success attendant on puncturing the tumours, especially where 
their contents were fluid, or viscid ; and, in one or two instances, where 
blood only escaped. By this operation, the bulk and tension of the 
tumour were diminished, and the double purpose was accomplished, 
of a partial removal of the obstacle delaying parturition, as well as a 
preservation of the growth itself from that severe pressure and contu- 
sion which may lead to rupture of its parietes, and inflammation or gan- 
grene of its substance. 

Six cases published by Mr. Park of Liverpool, in the Second Vo- 
lume of the Medico-Chirurgical Transactions, are equally in point. 
Puncturing the tumours was the most successful of all the measures 
adopted ; and it is worthy of observation, that the only fatal termina- 
tion occurred in a case where the tumour, occupying the recto-vaginal 
septum, was subjected to the pressure and contusion of the foetal cra- 
nium for three days. Delivery was eventually accomplished by the 
natural efforts, and the patient died in twenty-four hours, from vomiting 
and constipation. 

A perusal of all that has hitherto been written on the subject will 
satisfy any one, that the procedure to be adopted in these unfortunate 
complications, at the time of labour, is by no means clearly defined. 
If the opposing growth can be pushed above the brim, the difficulty is at 
an end ; but if it cannot be so raised, although puncture of the morbid 
structure is the best remedy for tumours with fluid contents, it will 
avail little in the management of solid and very hard growths. Ex- 
tirpation by the knife may be thought of; but the connexions of the 
tumour, the shock of the operation, the probable hemorrhage, and the 



COMPLICATED WITH ORGANIC DISEASES. 243 

subsequent inflammation are events too certain and too hazardous to 
allow of a favourable prognosis. 

These remarks are strictly applicable to morbid enlargements op- 
posing the descent of the child : but they are equallyv'jpertinent to hard 
and malignant tumours of the uterus itself, and to ovarian and other 
growths of such magnitude and firmness and attachment, as to preclude 
the possibility (vide Mr. Hewlett's and my own castes) of their being 
lodged in the abdominal and pelvic cavities, together with the gra- 
vid womb, without exciting pressure and contusion. This obser- 
vation is especially true where pregnancy is complicated with one or 
more hard tumours imbedded in the parietes. If the practice proposed 
were dangerous to the mother; if it increased her risk at the time, or 
if afterwards it placed her in a worse position than she had previously 
occupied — objections to it would carry great weight. It is, however, 
satisfactory to know, that none of these evils are the effect of prema- 
ture labour artificially induced../ 

I think, therefore, I may regard as proved, that great advantage 
will accrue from this methckl, where the tumour cannot be raised 
above the brim ; where it is "situated in the abdomen, and is of such 
size as to restrain the development of the uterus without painful pres- 
sure and contusion ; or where the growths occupy the uterus itself. 

Before concluding this chapter, I must allude to other affections 
complicating pregnancy, which, from the aggravated evils they produce, 
fully justify this practice. I do this with more satisfaction, as I find 
that Dr. Robert Lee, in a paper recently published in the Medical Ga- 
zette, confirms the value of the measure, so long recommended by 
myself, by a series of cases, of all which he remarks, u that premature 
labour was, or might have been employed with advantage." 

In the list of such maladies, must be included cancer of the os and 
cervix uteri, especially in the early stage, and even when destructive 
ulceration has occurred ; corroding ulcer and cauliflower excrescence 
of the os ; diseases of the vagina, urethra, labia, and perineum ; in all 
which, with varying probability of benefit, and in some with scarcely 
more than transient good, the measure may be adopted. From what 
has been said, it may be inferred, that circumstances must modify the 
propriety of the practice, and that the ultimate decision must depend 
on the judgment of the practitioner. 

In one instance, where Dr. Lee was consulted, the patient had been 
twenty-four hours in labour; the os uteri being hard, irregular, and 
ulcerated, and so little dilated, that the prostration could not be as- 
certained. Twenty-five ounces of blood were drawn from the arm, 
and one drachm of laudanum was administered. The perforator was 
eventually used, the idea of making incisions into the diseased os uteri, 
after consulting an eminent surgeon, having been abandoned. Death 
occurred soon after delivery, and on examining the body, the neck of 
the uterus, extensively lacerated, presented the appearance of an irre- 
gular, dark-coloured, disorganised mass. " The danger of dying un- 
delivered," remarks the author, "and the injury necessarily inflicted 
upon the uterus by the extraction of a child at the full period, would 
have been avoided or lessened by the induction of premature labour." 
It is easy to understand, where cancer of the lower portions of the 



244 



ON PREMATURE LABOUR IN PREGNANCY, 



uterus shall have advanced so far as to have destroyed their form and 
texture, that w*^e have no reasonable ground for hope from any means 
which maybe Employed ; but even here, forlorn as must be our expec- 
tations, it is better to induce labour prematurely, than to allow it to 
occur when tho distention of the growing ovum can be no longer 
borne, and whein, from experience, we know, that unlimited and al- 
most immediately fatal laceration must happen. Dr. Lee remarks, 
" that if abortion^ does not take place, where pregnancy exists with 
cancer of the os uteri in an advanced stage, the membranes of the 
ovum should be perforated ; and if the disease is less extensive at the 
seventh and a half mbrith." 

His case, No. 141, a\fords satisfactory corroboration of the opinion 
already expressed, that death in labours thus complicated, is mainly 
referable to what was found in -that instance, viz., " a tumour in a state 
of inflammation and suppuration, \ttaehed by a large root to the right 
side of the body of the uterus. The .peritoneum which covered it, ad- 
hered to the parietes of the abdomen, omentum, intestines, and liver. 
Numerous small fibrous growths, imbedded in other parts of the pa- 
rietes of the uterus, were in a healthy st^te." 

In Case 142, where pregnancy was 1 complicated with an ovarian 
growth, premature labour was induced in December, 1840. On Au- 
gust 10th, 1841:— Dr. Lee observes, "that the tumour has been con- 
siderably reduced in size since the repeated application of leeches, and 
the long-continued use of the liquo/potassae. The general health is 
nearly in the same condition as before pregnancy." 

There can be little doubt, that this practice will hereafter be gene- 
rally adopted ; where ovarian dropsy or ascites, organic affections of 
the heart and excessive sickness, render the continuance of pregnancy 
a matter of serious risk. 



pregnancy complicated with organic diseases. 

Case 54. 

The following Case I saw several times, in consultation with Dr. 
Robert Ferguson, of King's College ; and the details were communi- 
cated to me in a letter from himself. 

" On the 30th January, 1840, I saw Mrs. M , at the desire of Mr. Thompson 

of Blackmoor Street, who knew that she had a large pelvic tumour, and suspected that 
she was pregnant. I learned that she was 3f6 years of age, had been married two 
years and a half, and had miscarried at five months after her marriage. The grounds 
for her own belief in her pregnancy were, chiefly, that she, who had been previously 
regular, had ceased to be so since the 20th July, 1839 ; and that, moreover, she felt 
as formerly in her first pregnancy. External examination merely detected a large 
unequal tumour running across the hypogastric region, in which I could neither hear 
the sound of the so-called placental murmur, nor the pulsation of the foetal heart. 
Internally, I found the pelvis filled to three-fourths of its depth by a hard, smooth sub- 
stance, which was obviously situated behind the vagina and before the rectum. The 
upper part of the pelvic outlet was nearly obliterated by the tumour; the vagina 
was twisted so as to form a circular fold by the os tinea?, which rested over the 
symphysis pubis on the left side, so that it could with difficulty be reached, even after 



COMPLICATED WITH ORGANIC DISEASES. 245 

strong abdominal pressure had been resorted to, with a view to cause the uterus to 
descend. Not being able to ascertain anything satisfactory as to the main point, 
viz., whether this case of tumour was one complicated with pregnancy, I requested 
Mr. Thompson to auscult the abdomen very frequently, and to inform me of the re- 
sult. On the 5th March, this gentleman had no doubt of the fact, and I on that day 
both heard the placental murmur, and felt the movements of the child. 

4i It now became of serious moment to determine immediately our course of action ; 
and as the patient had, on a former occasion, consulted you, and'knowing the extent 
of your experience in these very cases myself, I gladly availed myself of your aid in 
assisting our deliberations. The rest of the history you are acquainted with. You 
know with what difficulty the membranes were perforated where the os uteri could be 
touched only at its posterior lip ; that in twenty-four hours after, labour commenced, 
when, instead of the head, we found the nates presenting. It became, as you are 
aware, advisable to bringdown a leg, in order to aid the expulsive efforts of the uterus, 
which were strong, though unavailing. An attempt was made to pass the hand into 
the pelvis ; and then I found that the tumour could be in some measure pushed up. Ne- 
vertheless, it being impossible to enter the uterus with the hand, 1 was constrained to 
pass up the blunUiook, and fix it in the groin of the foetus. It was after considerable 
traction that the body was brought down, as you well know, who assisted in the de- 
livery of a dead child. The placenta came away in a few minutes. I saw our patient 
three or four days after the labour, and found the vagina stiff, thickened, and coagu- 
lated into hard cords. About the third week, after a great deal of pain a very fetid 
mass passed away, without any gush of water, which the patient said was black and 
like a cow's teat. Mr. Thompson then discovered that the tumour was gone. I now 
examined the patient, and ascertained that there was a hard mass, the relics of a per- 
foration, in the vagina, through which the tumour had sloughed away, leaving the 
pelvis capacious, and in every rpspect natural. A few months after this,! once more 
saw Mrs. M., who was in excellent health, and found little or no trace in the vagina 

which could indicate the history of her perils and escape. 

" Robert Ferguson. 



Case 55. 
reported by mr. benjamin ridge. 

Mary , aged 34, living in the Westminster Road, has been married twelve 

years, without any previous occurrence of pregnancy ; has been a patient of Dr. 
Cholmeley, in Guy's Hospital. When visited, on the 13th of February, 1835, she was 
found with the bowels constipated, and the whole of the intestinal canal distended by 
flatus. Upon more careful examination, a large hard tumour was discovered on the 
right side of the abdomen, just above the ilium ; which she said had existed for many 
months, but which had latterly grown very rapidly. She complained of great pain, 
when it was pressed ; and even at other times it was often uneasy. 

According to her own calculation, she was advancing towards the sixth month of 
gestation, and had experienced all the symptoms usually attendant upon that condi- 
tion. She was ordered to take a mild aperient. 

At seven o'clock the following morning, hemorrhage from the vagina occurred ; 
and in an hour afterwards a male foetus was expelled. The abdomen continued large, 
and the pains did not subside ; and when the finger was passed to the os, which was 
fully dilated, the head of a second foetus was discovered. In two hours, this also was 
pushed into the world, the face lying forwards on the pubes. There was considera- 
ble delay in the expulsion of the placenta; and an apprehension existing that 
danger might arise from the tumour, Dr. Ashwell was sent for. On his arrival, he 
found the uterus large; and having introduced his hand into the uterine cavity he 
brought away the placenta, expressing his fears for the well-doing of the patient; 
not because she had lost some blood ot had been fatigued by the labour, but from 
the collapse into which she was fast sinking, and which he attributed to the tumour. 
The secalecornutum had been exhibited, but had failed to produce contraction. The 
abdomen continued to increase, rather than to diminish in size; and it was quite 
evident that there was a large growth connected with, if not directly attached to, the 



246 ON PREMATURE LABOUR IN PREGNANCY, 

uterus. In a few hours she died ; brandy and ammonia having been largely given, 
without producing more than a temporary effect. 

On the 14th February, the day after delivery, the body was inspected. The usual 
characteristic products of peritoneal inflammation were universally diffused through- 
out the abdominal cavity, but more especially about the uterus, its investments, and 
the tumour. The latter grew from the fundus, and appeared to be a continuation of 
its parietes, of scirrhous hardness, and only slightly vascular. On the posterior part 
of the growth there was a fissured softening, into which there had been poured some 
ill-conditioned, purulent fluid. In the walls of the uterus were deposited two rather 
large hard tubercles, in whose texture softening or breaking down had evidently com- 
menced. The structure of the uterus itself was otherwise quite healthy. 

In this case, the weight and situation of the principal tumour seri- 
ously obstructed the ascent of the uterus. It grew from and rested on 
the fundus, and probably excited premature uterine action. How far 
the tubercles imbedded in the sides of the womb might have prevented 
the development of their substance, it is not easy to determine ; but it 
is not at all unlikely that they may have aided the principal growth, 
in the production of the labour. It must be borne in mind, that there 
were here no evident causes inducing premature parturition: there had 
been no blow, no over-fatigue or exertion ; but there had been growth 
and pain of the tumour ; and to these, uterine action must, I think, be 
attributed. Another useful practical inference deducible from this 
case is, that to the growth, and the pain accompanying it, we must 
especially look, as our guides in the management; more particularly, 
as to the time when the uterus is to be emptied.* It is also worth 
while to inquire, what might have been, in this and in other cases, the 
beneficial effects of general and local bleedings, and of an antiphlo- 
gistic regimen, associated with perfect quietude, previously to partu- 
rition. 



Case 56. 

On Sunday, 8th of January, 1832, I met Mr. Callaway in consulta- 
tion, on the following case: — 

Mrs. , residing in Surrey, aged 44, has been married fourteen years; and 

eight years ago, she became the mother of a girl now living. Since this time, she 
has not been pregnant, and the catamenia have observed their natural periods. 

July, 1831, was the last appearance of menstruation. In September, she had two 
or three crushes of blood from the vagina, while walking in her garden: and a month 
subsequently, she suffered so severely from pain at the lower part of her abdomen, as 
to place herself under professional care. Mr. C. then visited her; and, on examina- 
tion, discovered a rather hard, round, and uneven tumour in the right groin, tender on 
pressure, and movable. There was no discharge; and as the uneasiness passed away 
no further notice was taken of it. 

In November, she was visited by Dr. Conquest, who carefully examined the os and 
cervix uteri. He found the os rather patulous, and the texture of the cervix, and 
parts adjacent, unusually soft. A tumour, apparently distinct from that in the right, 
was now perceptible in the left groin ; and Dr. C. was of opinion, that they were 

* It may, I think, be fairly presumed, judging from the extensive morbid processes 
evident in the tumour, that if gestation had not been brought to a premature close, 
the greater portion of the uterine growth would, by the end of the natural term, have 
been entirely softened and broken down. 



COMPLICATED WITH ORGANIC DISEASES. 247 

both produced by some morbid growth within the uterus, most probably the fleshy 
tubercle. 

January &:h, 1832. I can clearly trace a tumour, unequal on its surface, oval in 
shape, and wanting the firm, indurated feel of a healthy impregnated uterus, occu- 
pying the abdominal cavity, from the pubes to above the umbilicus, movable, and of 
the size of a six months' pregnancy. At its lower part, it is of very unequal hard- 
ness. The induration occupying the left groin is more defined, firm and resisting; 
while the portion of the tumour situated in the right, although distinct, is soft, and 
yields easily to pressure. 

The cervix has lost a considerable portion of its length ; the os is sealed ; and the 
body of the uterus is evidently enlarged. 1 cannot, however, balance the head of 
a child, nor can I form a correct opinion as to the character of the uterine contents. 
There is, undoubtedly, an unnatural feel about the parts : there is not the firm and 
healthy character of pregnancy. The weight of proof seems to incline to the fact of 
pregnancy in association with some morbid growths of tumours. There may be 
a blighted ovum, and an accumulation of hydatids or vesicles. Mrs. fre- 
quently feels something like the natural movements of a foetus, but still more fre- 
quently merely a fluctuation. She has suffered occasionally from nausea and vomi- 
ting, and many of the symptoms of easly pregnancy. 

It is now six months since the last menstruation ; and but for the occasional he- 
morrhages, the morbid growths perceived externally, and there not having been 
pregnancy for the previous eight years, and the period having nearly arrived when 
the function of reproduction generally ceases, there would not be any, or much hesi- 
tation. The circumstances perplex and complicate the case, and render it necessary 
to look well to her general health, and watch the further development of these inter- 
esting symptoms. 

In February, Sir Charles Clarke was consulted ; and after a protracted and careful 
investigation, confirmed the views already entertained : viz., " that it was pregnancy 
complicated with tumour." The balancing of the foetus was not accomplished, 
nor could any opinion be formed as to the presentation. 

At this time (February), and for some weeks previously, there had been frequent 
gushes of blood from the vagina, occurring without any unusual effort or exertion. 
These I regarded as indicative either of the attachment of the placenta over the os 
uteri, or as the result of the softening of the morbid growths : the former supposition 
was correct. 

On the 4th of March there was a large hemorrhage, accompanied by slight uterine 
pain. On examination, the os uteri was ascertained to be opening; and in a few 
hours I perceived the placenta to be attached over the os. I remained with my pa- 
tient, the late Dr. Key also being present; and about four o'clock a.m. of the 5th of 
March, twelve hours after the commencement of the flooding, and under collapse 
which precluded all hope, I introduced my hand through the membranes, thus par- 
tially detaching the placenta, into the uterine cavity. The liquor amnii had not es- 
caped ; there was therefore no difficulty in turning the child : and as the genital or- 
gans were relaxed, its birth was completed in a few minutes. The testicles were 
in the scrotum ; and from the general appearance of the child, 1 believe it was at the 
eighth month. 

Not more than half a pint of blood was lost during and immediately after the de- 
livery ; but her own powers gradually failed, and in a few hours she died. 

The inspection was made by Dr. Hodgkin, whose report I sub- 
join. 

"The external appearances offered nothing remarkable ; the body being free from 
discoloration, and not emaciated. The abdomen only was examined. The perito- 
neum was pale, and contained about a pint of sero-purulent fluid, of a light but soiled 
yellow colour, and of a highly viscid or ropy character : it bathed all the contents of 
the abdomen, and produced a smarting sensation on the hands immersed in it. The 
alimentary canal was distended by air, but, so far as it was examined, was free from 
any morbid appearances. The liver was pale and flabby; the spleen soft and of a 
light lilac colour. The uterus was rather imperfectly contracted, and of unequal 



248 ON PREMATURE LABOUR IN PREGNANCY, 

firmness, in consequence of the two considerable tumours to be presently noticed. 
Immediately under the peritoneal coat, at the anterior part, were two or three tuber- 
cles of semi-cartilaginous hardness; and two about as large as cob-nuts, rather vas- 
cular externally, and possessing an internal structure, evidently depending on cysts, 
and breaking down and softening. The two large tubercles, before spoken of, were 
each about the size of an orange, imbedded in the substance of the uterus, and pos- 
sessing a scirrhous character, and a structure dependent on cysts, but on a larger 
scale than in the scirrhous tubercle : they resembled fungoid disease. Considerable 
portions of both were breaking down, from the loss of their vitality; and presented a 
dirty, pale, yellowish-green. Intermixed with the livid colour, there was a little dirty 
fluid in the cells. The lining membrane of the uterus presented the dark colour and 
soft pulpy consistence usually met with soon after parturition. The ovaries were of 
moderate size, quite soft and lacerable : in one of them there was a distinct corpus 
luteum. The Fallopian tubes offered nothing remarkable." 

I have not often met with a case in which there was greater diffi- 
culty in determining the existence of pregnancy ; a difficulty so per- 
plexing, that it would, probably under any impression of the value of 
premature labour, artificially induced, have precluded its agency. It 
is, however, more than possible, that, even here, this plan of treatment 
might have done much good. 



Case 57. 
reported by mr. j. c. w. lever. 

Ann C- , Miriam Ward, Guy's Hospital, delivered May 26, 1834, of a living 

male child. 

This woman was admitted in September, 1833, into Dorcas Ward, under the care 
of Dr. Bright. There was then a tumour at the lower part of the abdomen, which 
had increased rapidly within the last three or four weeks. She first perceived its 
existence seven or eight years previously, as a lump immediately above the pubes. 
She had been married two years, but had not been pregnant. The catamenia had 
been always regular: bowels sufficiently open. 

Oct. 2. Dr. Ash well examined, and made the following report: — " Internally, 1 
find the os and cervix healthy, and of their natural size; neither is the body of the 
uterus enlarged. Externally, the hand may be passed between the lower edge of the 
tumour and the upper part of the symphysis, so as to feel the promontory of the sa- 
crum. On the whole, 1 am inclined to believe it to be an ovarian growth." 

Oct. 25. Complains of unpleasant sensations in the abdomen, and disinclination 
for food : there is no nausea or purging : the catamenia have been suppressed for ten 
weeks: the abdomen increases : breasts tender. 

Nov. 4. Dr. Ashwell reported, that " he believed the uterus unimpregnated." 

Jan. 24. Dr. Bright thus remarks: — "The tumour has changed its furm more 
within the last few days than ever before, projecting, in its upper part, to the right 
side; and she imagines she feels occasional motion within it." 

Feb. 2. Dr. Ashwell remarks that " there is considerable change, both externally 
and within. The tumour, which in October was low down in the abdomen, is now 
pushed up as high as the left hypochondriac region ; and in the centre of the belly, 
but more particularly on the right side, low down, there is fluctuation ; but there is 
nothing to be felt like the limbs of a foetus. The cervix uteri is remarkably altered, 
being soft, perfectly closed, and half an inch short of its natural length. On balan- 
cing the uterus, I thought something ascended, and then subsided again, as though 
I had displaced a foreign body. There is great obscurity about the case." 

April 19. Dr. Bright noted — " She feels movement much on the right side, and 
progressively enlarges." On several examinations with the stethoscope, by Dr. Ash- 
well and others, the placental soufflet and foetal pulsation were distinctly heard. 

At a quarter-past 6 p.m., May 26, Mr. Lever was called. He learned that there 



COMPLICATED WITH ORGANIC DISEASES. 249 

had been pains throughout the night: they now recurred, at intervals of about ten 
minutes. The os was dilated to the size of a shilling, and rio-jd. 

At 4 a.m., on the 27th, the membranes ruptured spontaneously, and the vertex 
presented. The child was horn at a quarter to 9. There was some resistance, occa- 
sioned by the thickness and rigidity of the perineum. The uterus contracted well; 
and the ovarian growth could be defined, occupying the left side of the abdomen. At 
12 o'clock she expressed herself comfortable. 

27th. Doing well. 

28th. 01. Ricini sfs. 

31st. The tumour has greatly increased in size, and is painful on the slightest 
touch. Pressure on other portions of the abdomen is unattended with pain. Bowels 
confined : pulse 130: tongue cracked and furred; countenance collapsed. 

Pul. Jalap, cum Hyd. submur. 5fs. statim. — Pil. Ant. Opiat. fort, cum 
Cal. gr. ij. tertiis horis. — Cataplasma Lini abdomini secunda qua- 
que hora renovandum. 

10 p.m. Has passed three dark fetid motions. Feels more comfortable. Pulse 
96. Less pain in the tumour. Lochia still flow. There is a scanty secretion of 
milk, and her aspect is still very unfavourable. 

June 1. Much worse this morning; there is considerable pain over the region of 
the tumour. Pulse 130: countenance anxious and distressed. 

Appl. Hirudines xv. statim, et postea cataplasm. Lini.— Sumat Pulv. 
Rhei cum Cal. 3fs. statim; et repetatur post horas quatuor, si opus 
fuerit. 

Half-past 8 p.m. The leeches have greatly relieved her, the pain and tenderness 
much diminished. Pulse 100: bowels open three times. She has vomited some 
vitiated bile. 

Hyd. subm. gr. iij. cum Pulv. Opii gr. fs. statim sumend. ; et quarta 
quaque hora repetend. 

June 2d, 1 a.m. She appears in every respect better. 

2 p.m. Pulse 100; bowels opened twice; mouth slightly affected; less pain and 
tenderness. 

June 3d. Pain increased over the abdomen: pulse quick and hard. 

Appl. Hirudines x. abdom. et postea cataplasm. Lini. — Omitt. Pil. — Mist, 
effervescens cum Tinct. Hyoscyami. m. xl. quartis horis sumend. 

4th. Bowels open ; pulse softer; les3 pain and tenderness. — Pero-at. 

5th. Greatly improved. 

6th. There is a recurrence of the abdominal pain and tenderness. 

Hirudines viij. abdom. applicand. postea cataplasm. Lini. — Hyd. sub- 
mur. gr. ij. Opii gr. fs. statim, et h. s. 

7th. The leeches have relieved her, although she is unable to move in bed with- 
out experiencing pain. The tumour, by pressing on the neck of the bladder, obstructs 
the passage of urine. A catheter was passed, and eight ounces of ammoniacal urine 
were drawn off, with great relief. 

8th. The tumour is smaller and less firm, and fluctuation is perceptible on the 
left side. There is a troublesome diarrhoea. 

Mist. Cretae cum Conf. Aromat. gr. x. et Tinct. Opii m. iij. tertiis horis. 
10th. The diarrhcea continues. 

Enema Amyli cum Tinct. Opii m. xl. statim injiciend. : et P. 

12th. is much improved, although weak and exhausted. 

Infus. Cusparise cum Ammon. Garb. gr. viij. et Tinct. Cinnam. gfs. ter 
die. P. — A pint of porter daily. 

15th. Much improved. The tumour is considerably diminished, and fluctuation 
is perceptible throughout: it does not interfere with the passage of urine.— Two pints 
of porter daily. 

18th. Gradually increasing in strength. 



250 ON PREMATURE LABOUR IN PREGNANCY, 

July 2. Her child died this morning, which has greatly depressed her. 

18th. Increasing in strength, and diminishing in size. 

25th. Transferred to Dr. Bright. 

March 20, 1836. The sister of the ward saw this patient a few days since, and re- 
ports, that the tumour is greatly increased in size since parturition. The catamenia 
have heen regular; but she frequently suffers pain in the growth itself. 



Case 58. 

OSTEOSARCOMA OF THE THIGH PREMATURE LABOUR ARTIFICIALLY 

INDUCED BREECH PRESENTATION. 

REPORTED BY MR. HENRY OLDHAM. 

Sophia B , Dorcas Ward, delivered of a still-born female child on the 2lst 

of June, 1835. 

This woman was a patient of Mr. Key, in Dorcas Ward. She was admitted, la- 
bouring under osteo-sarcoma of the knee, involving the lower half of the femur and 
the heads of the tibia and fibula. Owing to the rapid extension of the disease, it 
was evident that no time ought to be lost before resorting to amputation, the only 
means of cure. According to her reckoning, she was between seven and eight 
months advanced in pregnancy. In order, then, to allow the completion of the pe- 
riod of gestation, and the usual time of recovery, an interval of two or three months 
would necessarily elapse before the performance of the operation; which, from the 
rapid growth of the local affection, would then be rendered unavailable. Tt was 
therefore thought advisable to induce premature labour. 

Dr. Ashwell first attempted to effect this object, by detaching the membranes with 
his finger; but this proved insufficient for the purpose. He then punctured them by 
means of a catheter, containing a sharp-pointed silver wire; which, by communica- 
ting with a spring at the lower extremity, could be made to emerge at the point of 
the instrument, at the operator's wish. 

Having introduced the forefinger of the left hand within the os uteri, it served as 
a guide for the passage of the catheter, and thus the membranes were ruptured. An 
instant discharge of the liquor amnii succeeded, the whole of which was evacuated 
in three hours. 

The membranes were punctured at half-past nine a.m. on the 20th; at half-past ten 
a.m. she was ordered, 

Tinct. Secalis Cornut. m. xxx. ex. Mist. Camph. 3*. statim sumend. 

This draught was repeated at two p.m. No uterine action was established till one 
p.m. on the 21st. The pains were then feeble and transient. Shortly, however, 
they became more vigorous; and at half-past four p.m. she was delivered of a still- 
born female child, under a breech presentation. It may be here observed, that twenty- 
seven hours and a half elapsed between puncturing the membranes, and the commence- 
ment of labour, and fifty between the puncturing and the termination. 

June 22. Has slept well; no lochia; no milk; breasts cool and flaccid ; she feels 
comfortable, and is doing well. 

On the 30th of June, Dr. Ashwell thought her sufficiently recovered to undergo 
the operation. Hardly a trace of the lochia had appeared, and milk was not secreted. 
Mr. Key amputated the limb ; but, owing to the extension of the disease upwards, 
the tournaquet was obliged to be dispensed with, and pressure was made on the ar- 
tery just below Poupart's ligament. 

July 1. She appeared to have suffered very little from the effects of the operation ; 
she was cheerful and free from pain. Skin moist; pulse 82, soft. 

She continued daily to improve; the stump was healthy; and everything pro- 
mised a favourable issue. She steadily advanced towards recovery for four or five 
weeks, although in a very emaciated condition. Suddenly, however, during the very 
hot weather, without any apparent exciting cause, she began to sink; and in spite of 
all efforts to maintain her power she expired. 



COMPLICATED WITH ORGANIC DISEASES. 251 



SECTIO CAD AVERTS. — BY DR. HODGKIN. 



The head was not opened. 

The areolae about the nipples were very dark; the rete mucosum upon the breast 
and abdomen was also unusually so,and rather spotted ; there was a small soft tumour 
in the situation of the inguinal glands, on the rioht side. 

OCT* 5J 

The anterior part of both lungs appeared pale, and exsanguine. The pleurae were 
nearly or quite free from old adhesions; but there was some fluid effusion on both 
sides, with unequivocal traces of recent pleuritis on the left side, inferiorly and pos- 
teriorly : the pleura pulmonalis having at this part, a ihin layer of feebly-concreted 
lymph slightly adherent to it: the accompanying fluid was turbid and sanguinolent. 
The corresponding portion of lung was of .a deepish dull red, consolidated, and 
nearly impervious to air ; and having some small detached spots, formed by collec- 
tions of pus dispersed through it, and making their appearance upon the pleural sur- 
face, these spots appeared to be the result of the inflammation of particular lobules. 
In the same lungthere was one small well-defined tubercle, scarcely so large as a small 
marble, exhibiting the peculiar structure dependent on cysts, and rather of soft con- 
sistence : there was an equivocal appearance of another tumour, of smaller size. The 
right lung contained small collections of pus. These collections, like these in the 
opposite lung, appeared to be the result of acute inflammation of particular lobules. 
There was some recent inflammation in the surrounding pulmonary structure ; but its 
appearance was modified by cadaveric infiltration. No malignant tubercles could be 
detected in the substance of this lung; but one small calculus was found imbedded in 
healthy structure. 

The pericardium contained some fluid, but it did not appear to be unhealthy. The 
heart was flabby, and its substance very pale : it contained a feeble fibrous coagulum, 
with some fluid blood or serum. 

The general appearance of the viscera of the abdomen was healthy : there was 
merely a little effused serum, without any other indication of either old or recent peri- 
tonitis. The mucous membrane of the stomach was rather injected, and partly of a 
reddish dusky colour; but neither its texture nor its secretion appeared to be un- 
healthy. The duodenum was rather large ; its internal surface granular, the glands of 
Brunner being remarkably pale and prominent. The mucous membrane of the ileum 
appeared to be perfectly healthy. The aggregate glands, even at the termination, 
were very faintly visible. The mucous membrane of the large intestines was but 
imperfectly examined ; but where noticed, it appeared to be quite healthy. The ab- 
sorbent vessels on the surface of the liver were beautifully distinct. The incised 
surface of the Jiver exhibited little distinction of acini; and the substance was of a 
somewhat smooth plastic consistence ; the liver was not gorged with blood, and no 
tubercles of any description were detected in it. The gall-bladder was rather dis- 
tended. The spleen was large, turgid, and of remarkably dark colour; its incised 
surface exhibited a mottled appearance, conveying the idea that its dark colour was 
owing to sulphuretted hydrogen, the influence of which had not penetrated to every 
part. The emulgent veins were remarkably large, as was also the cava where it re- 
ceived them ; yet, in both situations, the venous texture appeared healthy, but imme- 
diately below, indications of inflammation commenced. A thin layer of concrete 
lymph slightly adhered to the internal surface of the cava ; the coats of the veins were 
found increasingly thick, as the pelvis was approached ; and at the termination of the 
cava, in both iliacs, as well as in some of their branches, they were nearly as thick as 
the coats of an artery. Though their calibre was large, they appeared, in some parts, 
to he corrugated ; and they contained an opaque, tender, dirty-white coagulum, fee- 
bly adherent, and intermixed with more recent red coagulum, or with a dirty puri- 
form fluid, which gave to these veins, when cut into, very much the appearance of 
little abscesses. Besides the opaque whitish concrete matter within the cava, opaque 
whitish spots were observed immediately beneath the lining membrane, at the most 
inflamed part; they bore the closest resemblance to the light atheromatous deposit 
so commonly seen beneath the lining membrane of the aorta. The veins in the pel- 
vis, especially those connected with the uterus, seemed to have been inflamed during 
the longest time and in the greatest degree. The neighbouring cellular membrane 



252 ON PREMATURE LABOUR IN PREGNANCY, 

was considerably indurated ; but was generally pale, and showed no disposition to 
suppuration. The uterus was as much contracted as could be reasonably expected : 
its substance appeared quite healthy: its internal surface still retained the evident 
marks of recent delivery: the ovaries were large; the spermatic veins were large, 
but not inflamed ; at most, they only contained recent coagulum. 1 he femoral vein, 
and its branches in the stump, were generally inflamed, but not so much near the ex- 
tremity as hio-her up. The last portions of the femoral vein and femoral artery were 
contracted upon clots of coagulated blood. The small tumour in the groin was caused 
by a suppurated absorbent gland : the veins about it were filled with fluid pus. J he 
epkastric vein was traced, in this state, for about four inches, where the vein ap- 
pealed healthy. The internal surface of the inflamed vein was quite smooth: its 
thin coats separated from its sheath of inflamed and indurated cellular membrane, 
very mu^h in the same way that the mucous membrane of the intestines may be 
detached from the other coats, in some cases of peritonitis. Bes.des the absorbent 
gland above mentioned, others appeared to be inclined to suppurate; and some of 
(hose accompanying the external iliac were a little enlarged, slightly indurated, and 
of a grayish colour"; but there was no appearance of malignant disease in them, nor 
in any other organ except the right lung. There was a small collection of pus near 
the end of the stump. 

Case 59. 

reported by mr. j. henry roberts. 

Mrs M , a widow, the mother of three living children, was taken in labour 

at 11 a.m , in January of 1834. The report commences at 4 p.m., when it was stated, 
by the aentleman who had been in attendance, that everything was proceeding favour- 
ably. On examination, however, the left foot was found low down in the vagina 
with the toes towards the pubes. The pains were irregular and inefficient, although 
it was stated they had been energetic. When they returned more vigorously, an 
attempt was made to turn the child's abdomen towards the sacrum of the mother, in 
order to facilitate its birth and protect its life. This effort was thwarted by a firm 
solid body projecting into the upper portion of the vagina, and so narrowing the pas- 
saoe as to oppose an effectual obstacle to an alteration of position, or to the further 
progress of the labour. The patient at this time was exhausted by her efforts: her 
pulse became quick, skin hot, &c, indicating a necessity for speedy delivery. Sud- 
denly, however, she complained of something giving way ; and on examination, it 
was found that all vestige of the tumour had disappeared, and that a black, fetid, 
viscid fluid had been discharged, probably amounting in quantity to thirteen or four- 
teen ounces. The delivery was shortly afterwards effected, although a slight antero- 
posterior contraction of the brim retarded it: the child was still-born. 

She appeared to rally an hour or two after the delivery, although the.e was a con- 
tinual draining of the same dark offensive fluid from the vagina. 

The following day she exhibited symptoms of collapse, with great pain in the Jell 
iliac and lumbal regions, ihe site of the tumour. As she had not emptied the bladder, 
a catheter was introduced, and about four ounces of urine were drawn off. In > s P ]te 
of all efforts at restoration, by stimuli, &c, she continued gradually to sink ; and died 
on the evening of the second day. 

An inspection was permitted. There were no traces of peritoneal inflammation. 
The uterus was found contracted to the size of a fetal head, and there was no discer- 
nible lesion in it. The left parietes had suffered pressure, from their proximity to the 
tumour. There was found a large cyst, emptied of its contents, growing from the 
ovarv; and which, if distended by fluid, would have occupied a space between the 
floating ribs and the cavity of the pelvis. The parietes of this cyst, in their lowest 
portion, had come in contact with the upper and left portion of the vagina, and, pro- 
bably by the pressure of the gravid uterus, had been detained there, till, by the suc- 
cessive processes of inflammation and ulceration, they had adhered to, and eventually 
discharged their contents through the vagina. The vagina, in this part, was in a gan 
grenous state, communicating, by an opening effected during the labour-pains, with 
the cyst. This rupture was doubtless the occasion of the sudden disappearance of 
the tumour, and the black fetid discharge. 



COMPLICATED WITH ORGANIC DISEASES. 253 



Case 60. 

MALIGNANT DISEASE OF THE EXTERNAL GENITALS, COMPLICATED WITH 

PREGNANCY. 

HEPORTED BY DR. JOSEPH RIDGE. 

Maria T , aged 38, a woman of middle stature, with a somewhat emaciated 

appearance, her countenance denoting anxiety and distress, was admitted under Dr. 
Ashwell, 30th of August, 1836. She is the mother of four children, the last of which 
was born three years° since. Her health has been good; and she has followed the 
occupation of weaving, excepting during the last three years, when she has been en- 
gaged as a nurse. She is now six mouths advanced in pregnancy; and the cata- 
me°nia havr recurred, though pale and scanty, and for two or three days only, during 
her present gestation. A°)out twelve months ago, in an attempt to raise a bulky 
patient, she strained herself, and felt something give way in the left groin, which 
was succeeded by a swelling about the size of a hen's-egg, and she was obliged to 
keep her bed. This gradually subsided, leaving the part hard and knotty; and the 
surrounding integument shortly assumed the same appearance. During the last live 
months, this disease has greatly increased, the parts becoming more swollen and 
vascular; and within the last month, ulceration with hemorrhage has commenced 
in the most prominent parts. This disease, which appears to be a carcinomatous 
tubercular deposit, extends, at present, from the left groin down to the labium, 
involving the upper part of the nymphae, and reaching the mons veneris, and on 
this side°the most projecting parts are ulcerated, discharging a thin ichorous fluid. 
The neighbouring integuments are occupied by distinct scirrhous tubercles. The 
right groin is legs' affected ; although its skin is elevated, and the right labium hard 
to the touch, and much swollen. The vagina is healthy. She suffers severe stab- 
bing pains in the diseased parts, and a more fixed pain in the back. Tongue slightly 
furred. Pulse soft and rather quick. Bowels open. The foetal heart and placental 
souffle were readily distinguished. 

. Cataplasm Conii part, affect. 
Jul. Ammon. Acet. cum Sp. Mth. Nit. et Tinct. Hyoscy. aa m . X x. t. ck 
Liq. Op. sed. m. ex Mist. Camph. o. n. 

The conium poultice failed to relieve the severe lancinating pains; and seme vin. 
opii, soaked in lint, was applied over the surface. She was ordered nutritious diet-, 
wine and porter, some ol. ricini occasionally, and a light bread-poultice was applied 
over the lint and vin. opii : by these means the acute pain was mitigated, but the dis- 
ease rapidly increased. In the course of a fortnight, the whole of the external parts 
of generation were involved ; the os externum was contracted, and some parts- were 
softening down. The anxiety of countenance became more confirmed; there were 
febrile paroxysms at night; the extremities were daily emaciating; and the pain was 
more severe. 

On the 23d of September, three weeks after her admission, Dr. Ashwell punctured 
the membranes with a view of inducing labour; and some liquor amnii immediately 
escaped. 

In nineteen hours afterwards, labour-pains commenced ; and during this interval" 
her local sufferings had been much relieved, and she had enjoyed several hours' 
sleep. Every advantage was afforded, by restraining the rapid advance of the fcetal 
head, for a gradual dilatation of the external parts; but as labour progressed, the labia 
became everted, and some dark grumous blood was discharged from the left. As 
the head was urged towards the outlet, it became evident that its exit could not oc- 
cur, without the tearing awav of a considerable portion of the di-eased structure and 
such a hemorrhage, as the enfeebled state of the patient's powers would ill sustain. At 
this time, Mr. Lever came to my assistance; and finding the head unusually firm and 
large., and that no pulsation was perceptible in the fontanelles, he determined to per- 
forate 'hecrar iurn. The w e.ter portion of the brain escaped, w'uh much blood ; and 

17 



254 ON PREMATURE LABOUR IN PREGNANCY, 

the uterine efforts quickly expelled the collapsed head, the shoulders and nates gently 
following it. A slight laceration of the fonrchette occurred, notwithstanding the 
firm support afforded to the perineum, hut it did not extend to the softer, or, rather, 
less scirrhous parts. The placenta soon followed. The uterus contracted firmly, 
and, excepting a slight oozing from the morbid growth, scarcely any blood was lost. 
The child was well formed, and a little beyond the seventh month. 

Sumat Tinct. Opii m. L. ex Aq. Menth. statim. 
Shortly after delivery, some brandy and water was administered, as she seemed ex- 
hausted. In the evening, she had passed urine without difficulty and was compara- 
tively free from pain. No hemorrhage. Thirst: pulse 130: fuller: skin hot. She 
was ordered, 

Cataplasm. Panis. part, affect.— Sago, Barley-water, &c. 
August 25. Countenance improved, and she feels better. Pain in the external 
parts returned in the night, which appear much the same as before delivery. Tongue 
moist: skin perspirable: pulse 125, soft and compressible : very little lochia. 

Toast and water, with Isinglass, Arrow-root, &c. 
Capiat Liq. Op. Sed. m. xxv. hora somni. 

In the evening there was a slight rigor; which was relieved by extra clothing, and 
warm applications to the feet. The abdomen somewhat fuller. 

01. Ricini eras mane, cum Tinct. Opii m. x. 

26th. Bowels twice relieved. There is some tenderness, on pressure, over the 
right side of the abdomen : the liver is large, and low down : the breasts are filling : 
pulse 125, compressible : heat of surface moderate; tongue more furred, inclined 
to brown. 

Vesperer The abdominal tenderness is increased, and there is more flatulent dis- 
tention ; complains of weakness, with lumbar pain ; some heat of skin. Pulse 135, 
compressible; very little vaginal discharge. 

Cataplasm. Sinapis abdomini. — Empl. Belladon. lumbis. — Applic. Hi- 
rud. x. Abdom. si dolor augeatur ; et postea, Fotus calid. 
B. Tinct. Castor. Sp. Lavand. C. aa ^ij. 
Amnion. Carb. ^j. Tinct. Opii 3j. M. 
Fiat mistura, cujus capiat cochl. i. min. sextis horis, ex aqua. 

27. Abdominal tenderness removed; skin cooler aud moist. Pulse 130, soft. 
There is pain about the left hip ; over which there is an erythematous redness. 

Fot. Papav. coxee. 

28th. She is looking much better; the abdomen is free from pain; erysipelas 
is extending over the hip, and there is effusion in the cellular tissue beneath: the 
mammae are distended and tender : they have been fomented, and the milk drawn 
from them by an exhausting-pump. Pulse 125, soft, and easily compressed : tongue 
moist. 

Beef-tea, Sago, Wine. 

29th. Improving; the erysipelas is less apparent. Pergat. 

30th. She has passed a restless night, and her countenance is now greatly de- 
pressed ; there is some tenderness around the umbilicus; bowels open ; skin very 
moist; respiration hurried; tongue becoming brown. Pulse 130; small, and easily 
compressed. 

Inf. Serpent, cum Ammon. Carb. gr. v. 4tis horis. 

Vespere. Flas passed three relaxed motions; no abdominal pain; respiration, 48 
in the minute. 

Enema Amyli cum Tinct. Opii gi. statim. 
Pil. Sapon. cum Opio gr. v. 4tis horis. 

Oct. 1. She is gradually sinking. The diarrhoea was stayed by the opiate and 
enema ; the skin is moistened with a cold perspiration ; the countenance is contracted, 
and fallen. Respiration 42, catching. Pulse 160. 

Brandy and other stimulants were administered ; but she died at 4, p.m. 



COMPLICATED WITH ORGANIC DISEASES. 255 



INSPECTION. 

The close pericardium presented three or four small hard tubercles: the pleuraa 
were copiously sprinkled with tubercles of the scirrhous kind ; some were minute, 
pale and firm : others, varying from the size of a pea, presented flattened hemi- 
spheres, whilst a few more nearly approached a medullary character: the lungs 
were doughy to the touch, and there were some medullary deposits scattered in their 
texture, of a redder and more opaque nature than those in the serous membranes : 
the peritoneum was bathed by a reddish turbid effusion ; and here and there, particu- 
larly on the portion covering the convexity of the iiver, were some thin feeble layers 
ot adherent fibrin ; the liver was greatly enlarged, and lay widely expanded over the 
other viscera; its texture was very coarse and soft; and it was extensively occupied, 
within, and upon its surface, with cerebriform fungoid deposits. Externally in the 
liver, they appeared as soft fluctuating projections, reddened by injected and extra- 
vasated blood. In the interior, these deposits were larger and more numerous; ap- 
pearing, in some parts as masses of white brain-like matter; whilst in others they 
seemed breaking down, forming cavities filled with grumous blood ; the greater por- 
tion of the inferior and upper part of the liver was thus either dissolving or entirely 
broken up. The spleen was similarly invaded ; the deposits were mostly of a lightish 
colour, and somewhat translucent ; and others were in a state ofecchymosis and soft- 
ening. 

The uterus was of the size of a moderately large orange ; its serous covering, clear 
and smooth ; the walls pale, loose, and flabby; the lining membrane was somewhat 
dark and turgid ; and in parts, especially where the placenta had been attached, it 
appeared coarse and rugged. The cervix was thin, soft, and flaccid ; the anterior lip of 
the os was tumid and hard, and the seat of a scirrhous deposit : the vagina, in its up- 
per part, was wide and smooth ; but below, the surface was firm and indurated. 

The lumbar glands were greatly enlarged, from a medullary fungoid degeneration. 

The other organs were healthy. 



REMARKS. 

A disease of the kind already described, coexisting with pregnancy, 
is, happily, not at all common : still there can be no difficulty or doubt 
as to the treatment. 

If the ulceration had been stationary, or limited to a circumscribed 
and small locality, it would have been right to have allowed gestation 
to proceed uninterruptedly ; as it was, the lives of both mother and 
child were endangered by the continuance of gestation : the former 
was compromised by the rapid progress of the ulceration, which in 
great measure depended on the excitement of pregnancy, and the in- 
creased vascular supply consequently furnished to the diseased struc- 
ture ; while the chance of preserving the life of the latter was daily 
diminishing ; for the foetal bulk was increasing, at the same time that 
the passage through which it was to be propelled was rapidly narrow- 
ing. 

If, therefore, the mother could have lived sufficiently long to have 
allowed of the completion of the term, it is all but certain, that the 
normal form and structure of the vagina and os uteri would have been 
so destroyed by ulceration, and by vascular fungous growth, as to 
have precluded any other method of delivery than by the Caesarean 
operation : nor is it at all probable that the life of the child could have 
been preserved, under such sufferings, emaciation, and exhaustion of 
the mother. These circumstances, then, determined me to bring on 



256 ON PREMATURE LABOUR IN PREGNANCY, 

premature labour ; nor does the result of the practice invalidate the 
correctness and expediency of the principle on which it rested. The 
patient's sudden and rather unexpected death was attributable to the 
latent peritoneal inflammation and intestinal disturbance ; induced by 
the very advanced state of hepatic disease, aided, perhaps, in some 
decree, by the tendency to peritonitis so common after parturition, 
and, as already observed, after any operation connected with the pel- 
vis or its viscera. 

The following observations were contained in a letter which I have 
received from Dr. Hodgkin ; and I have inserted them here, as they 
tend to give his authority in confirmation of the opinions already ex- 
pressed by myself in the body of the paper. 

« Before proceeding to make, as an appendage to thy paper, the few remarks which 
I am about to offer respecting those adventitious growths which are met with in the 
parietes of the uterus, and which are commonly known by the name of fibrous tuber- 
cles of the uterus, 1 would observe, that this term, which is inaccurate and fallacious, 
is the more to be regretted, because it has favoured the belief that these productions 
are of a nature sui generis, and altogether distinct from that of tumours of undoubted 
malignanry. A careful and patient examination will, I am satisfied, convince the 
accurate observer, that these growths essentially possess the structure of compound 
adventitious cysts, to which the malignant heterologue formations are to be referred. 
The appearance of fibres, which these tumours present, when a section has been 
made through them, is produced by the cut edges of the cysts of which the tumours 
are composed. If any doubt of the existence of this structure remain, after the in- 
cised surface has been earefully compared with the corresponding surface of other tu- 
mours unquestionably possessing this structure and belonging to the malignant class, 
it may be removed by the examination of the external surface of a tumour when 
carefully detached from the substance of the uterus in which it is imbedded. We 
may then perceive, not only the nodulous form, but even portions of the cysts ; 
although the intimate mutual adhesion of the subordinate parts, and the density and 
compactness of the structure which they constitute, are unfavourable to their com- 
plete dissection. 

"The anatomical character of these tumours may be still further demonstrated, by 
references to a series of specimens, exhibiting the gradations between the most com- 
pact uterine scirrhous tubercles and those cases in which, either from original pecu- 
liarity of texture or from changes which the tumour, when formed, has undergone, 
the structure of the tumour is made evident. In my paper on the anatomical cha- 
racters of some adventitious structures, I have mentioned a few of the circumstances 
which favour the production of dense, compact, and hard tumours in the substance 
of the uterus. These circumstances I have stated to be the steady but firm pressure 
which the substance of the uterus continues to exert upon ihe new growth ; by which 
very rapid development, and the formation of cells containing fluid, are prevented ; 
yet gradual progressive growth is allowed, and a sufficient supply of nourishment is 
afforded ; whilst the generally quiescent state of the fibres of the uterus, except 
during parturition, allows development to advance, without modification or inter- 
ruption. 

" Although I believe that these circumstances have considerable influence in 
giving the peculiar character to scirrhous tubercles of the uterus, it will be right 
that I should notice the fact, that I have once seen tubercles, possessing precisely 
the same characters, and about as large as cob-nuts, in the immediate neighbour- 
hood of a uterus in which scirrhous tubercles of the kind usually met with in that 
organ were present. With regard to these tumours external to "the uterus, and ap- 
parently only covered by peritoneum and cellular membrane, we have sufficient evi- 
dence that the favouring circumstances which I have mentioned are not essential, 
at least whilst the tumours remain of small size. 

"Although we do occasionally meet with adventitious productions developed in 
the uterus, differing in character from the ordinary scirrhous tubercles in that organ, 



COMPLICATED WITH ORGANIC DISEASES. 257 



ar 



— as, for example, that form which has been called the aura, gelatinous, or areoL. 
cancer, and the fungoid tumour, — nevertheless, the predominance of the one form, and 
the peculiarities which may frequently, if not always, be observed in those rare in- 
stances in which the other tumours before mentioned occur, evince the intimate rela- 
tion which exists between the character of adventitious giowths and the texture in 
which they are produced. It is on this principle that the pathological importance of 
thy paper rests ; and no cases can more satisfactorily illustrate it, than those which 
thou hast collected. In cases where scirrhous tubercles of the uterus have acquired a 
prodigious size, and yet retain all their characteristic hardness, and exhibit a tendency 
to that ossific deposit which at times takes place to a most remarkable extent in these 
tumours, the substance of the uterus itself, though enlarged to about the size which it 
attains at the sixth orseventh month of pregnancy, and much thickened as well as dis- 
tended, still retains great density and compactness of texture. But in those cases in 
which the tumours are of a soft texture, as well as of a considerable size, and appear 
either to have been of rapid growth, or to have undergone those changes which do 
not permit the tumour to be quiescent, but occasion its breaking down to a greater or 
less extent, the substance of the uierus is thick, fleshy, more than usually supplied 
with blood, and comparatively soft. If these conditions occasionally exist in the 
unimpregnated womb, to a degree which is sufficient to modify the structure and pro- 
gress of tumours developed in it, we must at once perceive that they must exist to a 
far (greater degree in the impregnated uterus, which receives so large a quantity of 
blood, and has its laxity and softness of texture so much increased? If, in the un- 
impregnated uterus, we sometimes find those conditions which promote such a change 
in the nutrition and development of scirrhous tubercles, that they approach more or 
less to the character of fungoid, and lose their tendency to continue in a permanently 
inactive state, we find them also in the gravid, and more especially in the parturient 
uterus, in conjunction with circumstances which tend to promote their breaking down. 
These facts, and the practical conclusions to be deduced from them, are, I believe, 
for the first time, pointed out in the cases and observations which thou art now pub- 
lishing. The changes which the tumours undergo, when they lose their permanent 
character, and which consist in their softening and partially breaking down, deserve 
some attention; as they exemplify the process which goes forward in malignant 
tumours generally. The breaking down of such tumours has been ascribed to ulcer- 
ation; but the process which they undergo is greatly different from mere ulceration ; 
il consists in the absolute death of a part of the tumour, which loses its colour, be- 
comes opaque and pale, and often of yellowish or greenish tinge. It then softens, 
possibly from a new arrangement of its own constituents ; but this effect is consider- 
ably increased, by the dead part of the tumour now becoming a source of irritation, 
and consequently occasionally an increase in the quantity of blood, both in the parts 
of the tumour retaining vitality, and in the neighbouring natural structure. Their 
inflammation, and sometimes ulceration, ensue: but the more common and remark- 
able result seems to be, the death of further portions of the adventitious structure, 
the softening of which is promoted by the increased afflux of fluids. It is obvious, 
that the farther pregnancy has advanced, the more likely are the compression and move- 
ments of the uterus, both before and during parturition, to produce the lesion of the 
tumours; and the more are these tumours modified in their structure, so as to favour 
the changes which follow." 



CHAPTER IV. 

ORGANIC DISEASES OF THE CERVIX AND OS UTERI. 

As introductory to the various organic and malignant affections of 
the inferior portion of the uterus, it is essential to premise, that there 
may be enlargement and hardness of the whole organ, and especially 
of its cervix, without malignancy ; such being the result of congestion 
and inflammation. 

Congestion of the Uterus.— There can be no doubt that m health, 
both the uterus and ovaries receive an increased supply of blood at 
each menstrual period, and that there is a consequent slight and tem- 
porary congestion. The occurrence, however, of secretion, quickly 
removes any chance of its permanency ; thus converting into a benefit 
what might, under functional derangements, as amenorrhcea, or dysme- 
norrhea, have become seriously prejudicial. Pathologists insist much 
on the danger arising from these monthly repetitions, where there is a 
tendency only to disease ; and explain on this principle the inveteracy 
of many affections, and the inefficacy of curative means. Professor 
Simpson, of Edinburgh (in the Library of Practical Medicine, vol. iv., 
p. 323), very ably expounds and defends this view ; and although he 
willingly allows, that under the healthy action of the system, this con- 
gestion can scarcely be regarded as morbid, yet that it certainly borders 
upon disease ; and in every slight derangement, either in the function 
or organization of the uterus, it readily passes into a concretion, which 
must be looked upon as a diseased state. Thus morbid uterine actions 
are aggravated, and their removal prevented, by these renewed con- 
gestions, and both acute and chronic affections are rendered more per- 
manent, and less amenable to remedies. 

In these opinions, to a considerable extent, I concur. Still I think 
they require qualification. This temporary congestion, which is strictly 
natural, if followed by menstruation, is only productive of evil when 
it is protracted and complicated with acute or chronic metritis ; then it 
is easy to understand that it may become seriously injurious, if prompt 
and vigorous antiphlogistic treatment be not used. Hitherto, I have 
thought, and I still regard the opinion as correct, that the regular 
return of the monthly secretion, is one great cause why many of the 
organic diseases of the uterus advance so slowly; an opinion con- 
firmed by the fact, that in numerous instances their progress is not 
conspicuously evident, till menstruation has finally ceased ; after 
which any increased morbid supply of blood may become station- 
ary, or concreted in the uterine tissue. A similar congestion may 
result from gradual amenorrhcea, or from the more sudden suspen- 
sion of the catamenial function. Under such circumstances, organic 



ORGANIC DISEASES, ETC. 259 

disease of the uterus has rapidly increased, and the attendant pain, 
previously very slight, has become distressingly severe. The de- 
cline of these evils not occurring till menstruation has been again re- 
stored. 

The causes of morbid uterine congestion, are circumstances produ- 
cing unusual determination to the organ, without a corresponding amount 
of secretion, either during, or in the intervals of menstruation, such as 
excessive venereal excitement and indulgence, passionate mental emo- 
tion, inordinate physical effort, too long riding on horseback, or fatigue 
in the erect posture, or frequent abortion. 

The local symptoms are, fulness and weight, with dull pain, not in- 
creased on pressure, in the hypogastric region ; a sense of uneasiness 
about the neck of the bladder, and at the anus. Occasional hemor- 
rhages, especially after exertion or sexual intercourse. On vaginal ex- 
amination, the uterus will be found distended with blood, imparting to 
the finger a swollen, doughy, (edematous feel. Generally it is pro- 
lapsed, the cervix spongy, and the os patulous ; but there is rarely ten- 
derness or heat. The speculum shows the injected, shining, and venous 
colour of the parts ; and a slight exudation of blood is frequently seen 
on the cervix. 

There is no affection in which the constitutional symptoms vary more 
than in uterine congestion. Sometimes there is scarcely any complaint, 
while at others, there are frequent febrile attacks, slight rigors, flush- 
ings, headache, nausea, and despondency. The mammas often pain- 
fully sympathise, and become suddenly larger, and tender on pressure. 
Hysteria is common. 

The treatment is by no means difficult, nor, indeed, is medical aid 
often sought, where the congestion occurs only at the menstrual pe- 
riods ; but when it is an attendant, as it most generally is, either on 
functional or organic uterine disease, it behooves us to treat it with the 
utmost care. 

Rest, in the recumbent posture, is indispensable ; without it, the con- 
gestion will increase ; the natural gravitation of the blood must aug- 
ment it, independently of the fact, that the uterus is, from its weak- 
ened state, predisposed to concretion of blood within its vessels. Fre- 
quently the supine posture alone is sufficient to neutralize the bad 
effects of the congestion. Where further means are necessary, bleed- 
ing and scarification of the cervix are superior to all others ; and if 
these are forbidden by the fears or fastidiousness of the patient, a small 
bleeding from the arm, immediately before, or at the commencement 
of menstruation, to the extent of four or six ounces, seldom fails to do 
good. In the interval, the alum hip-bath and a blister on the sacrum 
are of great service. 

Note. — The alum hip-bath may be prepared by adding eight or ten 
ounces of alum to as much water as is necessary ; the temperature 
should be kept at 96° or 98°, and the patient should remain in it about 
half an hour. The efficacy will be increased by reducing the tempera- 
ture. In summer this may be done rapidly, in winter it is needful to 
be more careful in the reduction of the heat. It is certainly an excel- 
lent auxiliary remedy in chronic congestion of the womb. 



260 



ORGANIC DISEASES 



Acute Metritis.- Acute inflammation of the womb is a rare disease 
in the unimoregnated state. It may attack either the serous or mu- 
cous investments ; but the substance or parenchyma of the organ, is 
its most frequent seat. Its immediate results are (Edematous enlarge- 
ment, and softening ; and if the inflammation be very severe pus may 
be infiltrated through some portions of its tissue, or as I have only 
once seen, a distinct abscess may be formed in the uterine panetes, or 
in the immediate vicinity of the cervix. In puerperal inflammations, 
pus is occasionally found in the veins and lymphatics ; and when un- 
impregnated, I have several times known half a pint, or even a larger 
quantity of pus, to be shut up in the uterine cavity, and afterwards, 
the obstruction to its escape being removed, it has been suddenly eva- 
cuated by the vagina, thus relieving all the symptoms. Such a case 1 
have described at page 144. Lately, I examined a uterus where fre- 
quent inflammation of the peritoneal surface had induced effusion of 
coagulable lymph, by which the ovaries and Fallopian tubes, on both 
sides, had been glued to the neighbouring parts. Sterility must have 
been the result. Gangrene is mentioned by Gooch,and one such case 
I have myself seen, as the result of acute metritis; but it is exceedingly 
rare, except in connexion with puerperal disease, lhe mamert are 
more, but not exclusively, prone to the affection ; and in both married 
and single women it happens most frequently about the period of cata- 

menial decline. . c 

Causes.— Exposure to cold, and consequent suppression ot menstrua- 
tion, stimulating injections and mental emotions, immoderate physical 
exertions, and sexual excesses, induce the disease. 

Symptoms.— In some instances it comes on suddenly and severely ; 
in others, the acute stage is slight and transient, and the affection 
quickly becomes chronic. Amongst its most prominent symptoms, 
are, pain deep down behind the pubis, or higher in the abdomen, af- 
fecting also the back and groins, and aggravated on pressure, mictu- 
rition and defecation. The pulse is generally quick, but not always 
either full or hard ; on the contrary, it is sometimes weak, and easily 
compressed. The skin is usually hot and dry ; occasionally, as well 
as the lower extremities, it is cold. The bowels are mostly consti- 
pated ; the stomach irritable ; the tongue dry and furred ; and there 
is often a disposition to syncope, especially on sitting up. Occasion- 
ally I have seen severe headache, with slight delirium, twitching ot the 
tendons and muscles, and alarming collapse, where the metritis has 
supervened on catamenial suppression ; arising possibly from the re- 
tention of what would have been eliminated by menstruation. It the 
disease occur during a menstrual period, the secretion is usually sud- 
denly checked ; if during the interval, the function will be suspended 
at least till the malady is cured. There are cases recorded one of 
which I lately saw, where acute metritis having come on from wet 
feet, during menstruation, the inflammation extended to the perito- 
neum and intestines, and death ensued at the end of fourteen days ; 
active treatment having been too long delayed. On a post-mortem 
examination, the uterus was found morbidly enlarged and softened. 



OF THE CERVIX AND OS UTERI. 261 

There was pus in the parenchyma, and in the veins, and the intestines 
were adherent from the deposit of partially organised lymph. 

Treatment. — Neither the diagnosis nor the treatment involves diffi- 
culty, if the case be early discovered. The lancet must not be omitted 
in the more formidable attacks, nor except in these, must its use be 
pushed far ; as topical bleeding by leeches on the groins, hypogastric 
region, or to the os uteri, or scarifications of the cervix, are generally 
requisite to complete the cure. The hip-bath, and a bran poultice over 
the abdomen, as hot as it can be borne, soothe and materially aid the 
intentions in view. The bowels must be actively purged, and when 
this is fully accomplished, if the pain continue, and in paroxysms, opi- 
ate injections into the rectum seldom fail to afford relief; and for the 
constant wearying pain after the attack, a blister may be applied over 
the hypogastric region. M. Lisfranc recommends general, and is de- 
terminately opposed to topical bleeding, in metritis of the unimpregnated 
womb. The hypothetical prejudices of M. Lisfranc must, in such a 
case, yield to practical results ; and certainly nothing can be more uni- 
formly beneficial than the local abstraction of blood. 
* Chronic Metritis. — Chronic inflammation of the womb is an exceed- 
ingly frequent disease, often affecting the whole organ, but more com- 
monly confined to the cervix. Sometimes it follows active inflamma- 
tion, but more usually it comes on slowly, and independently of an 
acute attack. The symptoms, though of the same kind, differ in de- 
gree from those attendant on the former inflammation. And there is 
nothing in which knowledge and accuracy are more necessary, than 
in the diagnosis of the conditions, and especially of the induration, in- 
duced by this insidious affection. It may be regarded as the neutral 
ground of organic uterine disease. To know that the alterations in 
the texture of the cervix are still of a simple kind, after inflammation 
protracted through many months, or even a longer period, to feel cer- 
tain, that a favourable prognosis may be justly given, require close 
and extended observation. But I am certain that for a much longer 
time than is generally supposed, a cure may be fairly anticipated ; and 
every day's experience convinces me, that assiduous treatment would 
accomplish far more than many practitioners venture even to hope, 
much less confidently to expect. Ulceration, suppuration, and indu- 
rated enlargement of the substance of the uterus generally, and espe- 
cially of its neck, may ensue from chronic inflammation. Ulceration 
will meet with attention hereafter, suppuration has already been dis- 
cussed, and the latter result deserves especial notice. 

I had lately the opportunity of examining a uterus, which had for 
many years been the seat of protracted, and somewhat severe attacks 
of acute and chronic inflammation, and about the real condition of 
which I had, during the life of the patient, many doubts. The os was 
patulous, and the cervix and body of the uterus much larger than na- 
tural ; but on making sections of different parts of it, there was no dis- 
tinct scirrhous hardness, and certainly no development of cystiform 
malignant structure. Still there can be no doubt that change of or- 
ganization takes place, and that conversion into real uterine scirrhus 
is the occasional result of insidious chronic inflammation. Such a fact 
should be an incentive to watchful and nersevering treatment. 



262 ORGANIC DISEASES 

The symptoms of chronic metritis are sufficiently distinct, if care- 
fully investigated. That there is a uterus at all, is, in perfect health, 
scarcely known by any indications marking its locality. But when 
the disease in question is fully established, its site will be pointed out 
by unusual sensations of weight and uneasiness, occasionally amount- 
ing to actual pain. Heat about the cervix vesicae, and a feeling of 
dragging and descent, prove the altered condition of the affected or- 
gan. Unusual pressure, anteriorly or laterally, or on the rectum, evi- 
dences its unnatural position and bearing. The discharges accom- 
panying the affection vary. Sometimes a transparent, mucus, like the 
natural secretion in excess, or a more viscid and opaque discharge ; 
at others, a muco-purulent fluid, mixed occasionally with blood, and 
more rarely, considerable hemorrhage, mark the continuance of the 
malady. 

It is after the persistence of these symptoms for some weeks or 
months, the sallow countenance, the impaired appetite and digestion, 
abdominal pain, slight emaciation, and a gradual loss of strength and 
appetite, excite apprehension, and an examination being solicited, is 
generally readily granted. The uterus is almost invariably enlarged, 
and often considerably indurated, and on balancing it on the finger, 
its increased weight is evident. The cervix, from infiltration of lymph, 
is frequently hypertrophied ; its mucous follicles being filled with fibrous 
effusion, are prominent, and project unduly beyond the surface. Such 
a state may be regarded as entirely topical, and perhaps as indicative 
of the commencement of cancerous disease ; but it would probably be 
more correct to view it as part of the general consequences of the me- 
tritis, which has affected the whole uterus. This peculiarly elevated 
state of the uterine mucous follicles has been denominated the granular 
inflammation of the cervix, a term also used, when the mucous sur- 
face of the neck is studded with the effused lymph, in the form of red 
or highly-coloured granulations, instead of its being infiltrated into the 
follicles or crypts. The cervix is more bulky and doughy in feel, and 
the os uteri is found to be softer, more widely open than natural, and 
often, in some part of the aperture, there is tenderness or pain, with a 
roughness amounting almost to abrasion. On many occasions I have 
used the speculum, having had my fears excited, and usually there 
has been increased redness, and the blood-vessels have been more nu- 
merous. In two instances lately, the extremely distinct and strong 
pulsation of the arteries of the cervix surprised me. If it be asked 
whether such a state frequently precedes scirrhous deposits or ulcera- 
tion, I would reply, while there can be no hesitation that malignant 
disorganization does follow such an affection, yet that in general the 
induration and bulk of the cervix, and of the uterus generally, is 
amenable to remedies ; and if laying aside every preconceived opinion, 
the treatment presently to be enjoined, be carefully pursued, a favour- 
able result may fairly be expected. Doubtless, an intractable chronic 
inflammation of the neck of the uterus, especially in a strumous pa- 
tient, is a very anxious condition ; and if malignant disease be heredi- 
tary, if a mother, or sister, or other near relatives, have been destroy- 
ed by cancer, the prognosis should be a cautious one ; but if the indi- 



OF THE CERVIX AND OS UTERI. 263 

vidual has been previously healthy, and of healthy parentage, such an 
assemblage of morbid symptoms will generally be recovered from. 

Treatment. — So long as there is increased activity, either of the ge* 
neral, and especially of the uterine circulation, evinced by local pain 
and sensibility, topical depletion ought to be employed: cupping in the 
loins, and leeches to the perinaeum, and particularly to the cervix itself, 
and scarification of the latter part, are most useful. The hip-bath, as 
recommended in dysmenorrhoea, mild saline laxatives, and a milk or 
unstimulating, yet nutritious diet, the recumbent position, abstinence 
from sexual intercourse, country or sea air, and freedom from every 
kind of excitement, are essential. It is scarcely necessary to observe, 
that all the concomitant symptoms must be met by appropriate reme- 
dies; and it must not be expected, that the uterine enlargement, and 
the induration of the cervix, will pass away, till this protracted inflam- 
mation of its substance has ceased to exist. When the increased 
quantity of blood, which has so long circulated through the vessels of 
the uterine parenchyma, is diverted to its natural channels, then, but 
not till then, will the enlargement of this important viscus gradually, 
but very slowly, disappear. Nor can it be too strongly urged that 
iodine, mt. y, conium, lime, or arsenic, will exercise no beneficial 
influence in exciting absorption, till local depletion, aided by other 
means here pointed out, have lessened or subdued the existing inflam- 
mation. It will occur to almost every practitioner, how often he has 
verified this remark in the rapidly beneficial effect in other local in- 
flammations, of well-timed general or topical depletion. In some 
dropsical affections, one bleeding seems at once to stimulate the ab- 
sorbents, by removing the existing inflammatory action, these vessels 
having till then been uninfluenced by mercurial and other stimulant 
medicines. 



' CANCER OF THE UTERUS. 

Definition. — A disease sometimes hereditary, almost uniformly fa- 
tal, and most commonly, but by no means invariably, occurring at the 
period of catamenial decline, or at a more advanced age. Its special 
seat is the glandular apparatus of the cervix, commencing as a depo- 
sit of a peculiar substance, with induration. Sooner or later, ulce- 
ration occurs, after which it contaminates, transforms, or destroys sur- 
rounding parts, displaying a remarkable tendency to the production 
of fungoid growths in the seat of the ulceration. It is generally at- 
tended by cachexia and emaciation, and there is often considerable, and 
not unfrequently intense, pain. 

A volume of no inconsiderable size might be filled with an abridged 
detail of what has been written on cancerous affections of the womb ; 
and it would ill become me to underrate, either the truth or value of 
many of these contributions. If, therefore, with a view to avoid un- 
necessary prolixity, I may quote but little, and may therefore seem to 
appreciate these productions insufficiently, let it be understood, that 
the apparent want of respect really arises from my having seen the 



264 ORGANIC DISEASES 

disease so frequently, that the views which I entertain, particularly of 
the incipient stage, must almost of necessity be expressed and classi- 
fied, in a method somewhat peculiar to myself. 

Two points, in reference to this most direful malady, may be re- 
garded as fully established: — 

First, That it is malignant ; and 

Second, That its special seat is the neck of the uterus. 

There is a question, however, which may perhaps admit of doubt, 
viz., 

Whether prevention of further mischief \ presuming the disease to be 
in its incipient stage, or a cure of that which already exists, may be rea- 
sonably hoped for. 

And before entering more fully into the history and symptoms, I 
shall briefly pursue this most interesting inquiry, commencing my ob- 
servations by reiterating an opinion expressed by myself (in Guy's 
Hospital Reports, January, 1836, p. "153), "that hard tumours of the 
cervix, and indurated puckering of the edges of the os (conditions 
which frequently terminate in ulceration), may be melted down and 
cured by the topical application of iodine, aided by the recumbent 
posture, abstinence from sexual intercourse, cupping on the loins, a 
mild, unstimulating, and often a milk diet, gentle aperients, narcotic 
injections into the vagina, and the almost daily use of the warm hip- 
bath." 

It has been doubted whether I have sufficiently defined the nature 
of these hard tumours; whether, in fact, they are to be regarded as 
cancerous, or merely as congestions and ulcerations, which not being 
malignant, are capable of cure. I believed at the time I wrote these 
observations, and I still adhere to the opinion, that they were malig- 
nant tumours; but that their full development was prevented, at this 
early period, by the treatment pursued : for I have long been convinced, 
that cancer of the womb may be arrested in its early stages by the re- 
moval of the pathological state, of which it is the consequence. At 
page 145 of the first volume of the Reports, the following observations 
occur: — "To suppose, or to call these hard tumours scirrhous, cancer- 
ous, or malignant, would in some minds instantly excite prejudice. If 
I am censured, then, for using the term 'hard,' I justify myself by say- 
ing, that it is the best and least controvertible expression with which 
I am acquainted. It is scarcely possible to avoid attaching a precise, 
and perhaps an erroneous idea, to such terms as 'scirrhous,' 'cancer- 
ous' or 'tubercular indurations.' The denomination 'hard tumours' 
has this advantage — it assumes only a degree of hardness, or firmness, 
beyond that which is healthy and natural, leaving the precise cause of 
such hardness to be decided by the result of the treatment, or to the 
further progress of the disease. Such a condition may be the effect 
of chronic inflammation only; or, if of malignant character, it may 
yet be very distant from that degree of malignancy which will resist all 
treatment. 

"Nevertheless, I am persuaded, if many of these structural changes 
(in the os and cervix) were examined without reference to their treat- 
ment at all, and especially by iodine, they would be pronounced to be 



OF THE CERVIX AND OS UTERI. 265 

scirrhous or malignant alterations. I am not, however, pertinacious 
on this point : it is not a matter of practical moment ; although my 
conviction decidedly is, that these changes, whatever may have been 
their precise character at the commencement of the iodine treatment, 
would, without that treatment, have proceeded on to ulceration, and 
thus have left the patients with but a slight chance of recovery. 

1 Until I employed the iodine, especially in the forms of ointment 
and tincture directly to the diseased growths, and the treatment al- 
ready pointed out, I saw these indurations gradually getting worse : 
I perceived them slowly softening ; till at length their surfaces were 
broken, and ulceration occurred. Jt is needless to say, that, after this 
event, constant irritation, fetid and sanious discharges, and occasional 
hemorrhages, sooner or later induced a fatal result. I have ex- 
amined many of these structural alterations with great care, both by 
the finger and the speculum ; and, after repeated investigations, ex- 
tending over several years, I am not disposed to think less favourably 
of the treatment." 

In these views Duparcque and Montgomery fully coincide, and I 
regard it as of great moment, that in a matter so- truly important as 
the prophylactic treatment of cancer of the womb, the experience of 
these distinguished physicians should coincide with my own. The 
former has arrived at the following conclusions : — 

1. "The greater part of confirmed cancers of the womb succeed to 
congestions and ulcerations capable of being cured: we may then, to 
a certain degree, prevent the development of these maladies by pro- 
perly treating, at an early period, the primary pathological states of 
which they are the consequence. 

2. ' Once fully developed, confirmed cancers are, at present, beyond 
the resources of medicine: even surgical treatment, which offers some 
chance when the disease is limited to the neck of the uterus, is of no 
service when the entire organ is affected. 

3. " In all cases, a well-directed palliative treatment of symptoms 
will arrest the progress of the complaint; render it in some degree 
stationary, and relieve the most painful symptoms and the gravest 
1 accidents,' or at least so far mitigate them as to render less painful 
the approach of death. 

4. ' All the cases of extirpation which have been published, were 
so at a period too near the time of the operation (four, five, or six 
months at most) fir us to judge fairly of it. It is probable that a 
greater delay would have afforded even less encouragement." 

Dr. Montgomery (Dublin Journal, January, 1842, p. 433) thus ex- 
presses himself:—" The disease of cancer uteri is too universally re- 
cognised as one of the most frightful scourges of humanity, to render 
it necessary for me to attempt any description of its horrors, or to 
impress on even the most junior of my readers, the importance of 
closely studying the phenomena of an affection hitherto found so 
utterly intractable by every known means, and which, when once fully 
established, entails upon the unhappy sufferer one unbroken train of 
miseries, from which, it has been truly said, < temporary relief can be 
found only in opium, and permanent rest only in the grave.' But I 



266 ORGANIC DISEASES 

am perfectly convinced, from many years' observation, that some- 
thing may be done to stem, at its source, the torrent of agonies that 
will otherwise overwhelm the patient ; nay, I firmly believe it may, in 
many instances, be altogether turned aside, and the victim be rescued 
from the sad fate impending over her. 

" I am satisfied, that there is a stage of cancer uteri which precedes 
the two usually described by authors; a stage, in which the nature of 
the disease may be detected, its further progress arrested, and its 
germs destroyed, and the reason why this stage is not more gene- 
rally recognised is, that the accompanying symptoms are frequently 
so slight as to attract very little the attention of the patient, and thus 
are suffered to remain without treatment, until a profuse hemorrhage 
or some violent fit of pain sounds the alarm, and then, on examination, 
the disease is found to have passed into its second stage; the surrounding 
tissues are indurated and consolidated with the organ concerned, and no 
human means hitherto discovered can do more than blunt the thorns 
thickly strewn along the path, which the sufferer must tread, to < the 
house appointed for all living.' " 

It may not be without its advantages to pursue this part of the sub- 
ject further, and to state as exactly as possible, in what this curable 
stage really consists, and how long' it lasts. This is clearly not only 
the most novel, but the most useful portion of the history of cancer ; 
and if the facts to be adduced shall aid in the establishment of a cor- 
rect pathology, and of a prompt and efficient treatment, the labour it 
may cost will have been well bestowed. 

Authors entertain various opinions of what may be regarded as the 
first stage of cancer of the neck of the womb ; but all agree that soft- 
ening, abrasion, and ulceration of the indurated tuberculous deposits, 
place the disease beyond the reach of cure. Thus, the ground for 
hopeful treatment is strictly limited. 

Dr. Montgomery is fully satisfied, " that in the great majority of in- 
stances, the first discoverable morbid change which is the forerunner 
of cancerous affections of the uterus, takes place in and around the 
muciparous glandular, or vesicles, sometimes called the ova nabothi, 
which exist in such numbers in the cervix and margin of the os uteri ; 
these become indurated by the deposition of scirrhous matter around 
them, and by the thickening of the coats, in consequence of which 
they feel at first almost like grains of shot or gravel, under the mucous 
membrane ; afterwards, when they have acquired greater volume by 
further increase of the morbid action, they give to the part the une- 
qual, bumpy, or knobbed condition, like the ends of one's fingers drawn 
close together. When this second stage (usually described by writers 
. as the first) is established, all means hitherto devised have failed in 
producing any permanent beneficial effect." 

M. Duparcque is evidently somewhat in advance of this opinion, 
regarding u the greater part of confirmed cancers of the womb as suc- 
ceeding to congestions and ulcerations (doubtless with induration), ca- 
pable of being cured." In this passage, M. Duparcque must be under- 
stood as maintaining the frequent curability of these congestions and 



OF THE CERVIX AND OS UTERI. 267 

ulcerations, which, as they immediately precede, must be taken to be 
the first stage of the malady. 

With both these writers, and especially with the clear and practical 
observations of Dr. Montgomery, my own experience coincides. 
There is a vagueness about the " congestions and ulcerations" of M. 
Duparcque, which may perplex. It is somewhat singular, that in 
scarcely any of the treatises on cancer within my knowledge, is there 
any positive and direct allusion to a curable stage. Every friend to 
his species, therefore, must desire that these opinions may be sustained ; 
and there seems good reason to hope that they will, as the views them- 
selves are supported by facts, and there is nothing empirical in the 
method of treatment. It would exceed the scope of this work, to enter 
largely into controversial views of the specific nature of malignant 
disease ; and it would be unprofitable, in the present state of our 
knowledge, to attempt to determine, whether in the first stage of can- 
cer of the cervix uteri, there is more than the results of chronic in- 
flammation. At all events, no evil can arise from sentiments which 
shall induce prompt and powerful means of relief, based on illustra- 
tive and confirmatory cases. 

It is really admitted, that this prophylactic treatment involves the pos- 
sibility of a recognition of the disease prior to the commencement of the 
active stage. Of this, where early examination is practised, I have no 
doubt; andM.Littre believes that the development of thepoison might, in 
some instances, be warded off by a change of climate and food, and by 
the administration of chalybeate and mineral water. Nor can it, per- 
haps, be doubtful, that some of the tumours referred to by M. Recamier, 
and others, were really cancerous ; and if reliance be placed on the 
fact of their removal, it follows that in certain singular cases, pressure, 
aided by iodine, mercury, and other remedies, did fully accomplish a 
cure. 

Although it may be somewhat difficult to appreciate the exact ex- 
tent and duration of this favourable stage, it will be easily perceived 
when the disease has travelled beyond its limits. I am aware it 
may be urged against the reality of the cure, or the arrest of the ma- 
lady, that the incipient stage of cancer is occasionally protracted to 
several years, even where treatment is entirely neglected : but this can 
scarcely impugn the value of the measure now urged, as during any 
portion of the time the disease is thus inactive and stationary, it re- 
mains without diminution. But it is not so where powerful and per- 
severing treatment is in efficient operation ; in such case the disease is 
retrograding; the congestion, puckering, and induration, and the mor- 
bid state of the mucous linings are gradually and perceptibly lessening, 
facts satisfactorily proved by repeated examinations with the finger 
and the speculum. Doubtless there are many circumstances which 
will modify the prospect of success : these will, of course, attract no- 
tice when we come to the prognosis. 

The cases published by Dr. Montgomery, of which an abridged de- 
tail will be given, and my own, will probably fully substantiate these 
and other important positions. 

Cancer is not often a disease of the young; although some years 



26g ORGANIC DISEASES 

ago I attended a case with Dr. Pierce, where the patient had not 
reached her twentieth year. Boivin and Duges, in 398 examples, found 
twelve under twenty years of age ; 83 between twenty and thirty ; 102 
between thirty and forty ; 106 between forty and forty-five ; and 95 
between forty-five and fifty. Mr. Carmichael saw a case at twenty- 
one years of age ; and Wigaud adduces one of scirrhous uterus at 

fourteen years. 

The progress of cancer of the womb is remarkably diversified ; not 
only during the incipient stages, but even after the commencement of 
ulceration. In women of dark complexion, the malady advances for 
the most part slowly ; while in the fair and ruddy, where the capillary 
circulation is vigorous, its various stages are more quickly passed 
through, and death often occurs in a few months. A severe illness, 
or distress of mind, frequently gives a sudden impulse to the disease: 
and one cannot fail to be struck with the decided alteration fctf the 
worse, which so commonly and quickly succeeds events of this kind. 

Formerly, it was a matter of doubt whether pregnancy was a pos- 
sible complication of cancer ; now, not only the fact itself, but the very 
injurious, and often fatal, effects of pregnancy, so complicated, are 
fully acknowledged. To say that the mind and temper exert a marked 
influence over the progress of cancer, will not excite surprise ; and 
certainly, active and painful intellectual efforts, and an easily excited 
and irritable disposition, and a proneness to constant thinking about 
the disease, are sure to increase its activity. Sometimes, although far 
more frequently the reverse is the case, the complete decline of the ca- 
tamenial function, after months and years of irregularity, appears^ to 
suspend the further advance of the malady. Nor are there wanting 
examples, where, independently of any direct or appreciable causes, 
its progress is arrested. Unhappily, in the generality of instances, 
these are but temporary respites, although in the early examples ad- 
duced by Dr. Montgomery, and myself, the delay has been sufficiently 
long to induce the hope, under continued care and treatment, of its 
permanent duration. I am unwilling to lay more stress on this curable 
stage than the facts may fairly warrant, but I cannot resist the con- 
viction, whatever pathology of cancer may be adopted, that it is our 
duty to oppose the influence of preconceived and prejudiced opinions 
of its absolute incurability, and at least to allow the fullest and most 
persevering trial to the means employed. 

Early symptoms.— Sharp, and for a long time, comparatively tran- 
sient pains in the back and loins, coursing along the crests of the ilia, 
and terminating in the groins, or shooting down the fronts of the thighs. 
Sometimes the pain seems to pass along the sciatic nerve, and I have 
known partial paralysis induced by it. 

It must be recollected, that it is not the occasional occurrence, but 
the frequent return, and eventually the persistence of, these pains, which 
excite and fix the patient's attention. 

Doubtless, in some instances, menstruation is early deranged, but not 
commonly ; nor is there as a general attendant, at least early in the dis- 
ease, either leucorrhceal or other discharges. Occasionally there are 
slight and sudden hemorrhages^ for which a true or supposed cause is 



OF THE CERVIX AND OS UTERI. 269 

generally found, in irregular menstruation, or in some over-exertion. 
Irritation of the bladder, and more rarely dysuria, are among the early 
symptoms; and sometimes pain during intercourse admonishes the pa- 
tient that all is not right. 

Emaciation, and a discoloured skin, impaired sleep and appetite, 
and painful expression of face, belong for the most part to a later pe- 
riod, and will be hereafter described. 

Examination per Vaginam. — As the disease consists in an addition 
of new, although morbid material, the local symptoms must be impor- 
tant, even in the incipient periods ; and so far as my observations have 
gone, the os and cervix present, when thus affected, three kinds of 
induration : — 

1. The rima, or circumference of the uterine aperture, may be wholly, 
or only 'partially, hardened and puckered. 

2. The cervix may be hard throughout its whole structure ; or 

3. Hard tumours may be deposited in any portion of it. 

I am quite aware that tact, and a somewhat extensive knowledge of 
the normal or healthy varieties of these parts, are necessary for ac- 
curate diagnosis. The practitioner, therefore, will do well to re- 
member, that independently of disease, there may be, 

(1) A large and firm cervix. 

(2) A capacious, patulous, and firm os ; and 

(3) An os fissured, and unequally hard. 

I need scarcely occupy any time in explaining how it is that struc- 
tural lesions of these parts of the uterus are so much more dangerous 
than similar affections of the walls or body. The walls are simply 
containing parts, their structure being adapted to the function they 
have to perform. With the exception of the mucous tunic, or lining 
of the cavity of the uterus, which secretes the catamenia and the thin 
fluid lubricating its sides, the tissues composing the uterine walls are 
only called into healthy functional activity during utero-gestation and 
parturition : in the former state, their fibres are developed, and thrown 
into more distinct fasciculi or bands; and in colour, elasticity, and 
strength, they then closely resemble muscular substance in other 
parts. 

The structure and functions of the cervix present points of striking 
contrast in all these particulars ; for instance, the substance of the 
cervix is more compact, welted, and condensed, than any other part 
of the organ ; and, for the purpose of affording support to the super- 
incumbent viscus, it is intimately connected with the vagina, rectum, 
and bladder, especially with the vesical neck. The cervix possesses, 
also, sebaceous or glandular follicles, whose office consists in the se- 
cretion of adhesive mucus, for the lubrication of the parts durino- the 
unimpregnated condition, and for sealing the lips of the os after 
conception. To the additional circumstances, then, of its compact 
substance, its confined situation, and its glandular follicles, consti- 
tuting, as a whole, an elaborate and complicated structure, we may 
attribute the increased danger and rapid course of its organic lesions. 
A tumour of large size, affecting the uterine walls, finds space for its 
bulk without seriously encroaching on any neighbouring viscus : and 
18 



270 ORGANIC DISEASES 

if it once rise above the brim, like a pregnant uterus, it will obtain 
accommodation in the abdominal cayity, without any formidable dis- 
placement of the intestines. 

It is not so, however, where there is a tumour, or general induration 
of the cervix. The bladder, the urethra, the rectum, and the vagina 
are soon pressed upon, and functionally deranged ; irritation is excited ; 
and an increased supply of blood is quickly furnished to parts, whose 
safety would have been best consulted by a diminution of their natu- 
ral quantity. In addition, also, allusion may be made to the injurious 
effects on the os and cervix, in such a state ; of sexual intercourse, and 
of acrimonious discharges. 

Causes. — Much of the controversy which has existed on the etiology 
of cancer, has been settled by the accurate observations of modern 
pathologists. Whether, for instance, cancer did not depend on a 
specific cause, and might not be transmitted from one person to an- 
other by inoculation, or even by infection, was formerly a matter of 
doubt ; and although the affirmative of the proposition was generally 
assented to, yet of late years, it has been experimentally disproved ; the 
ichorous discharge of cancerous sores having been placed under the 
skin by inoculation, without any specific results. Dupuytren indeed 
introduced cancerous structure into the stomachs of animals, and in- 
jected the matter from cancerous ulcers into their veins, with no other 
result than irritation. Nor, although several such cases have fallen 
under my notice, have I ever known any specific ulceration arise 
from sexual intercourse with women who had open cancer of the 
cervix uteri. 

Predisposing Causes. — All circumstances by which the constitution 
can be prepared for the influence of the direct causes of the disease, 
belong to this class. The records of Guy's Hospital, and ray own 
practice prove, that from thirty to fifty-five years of age is the period 
most favourable for the development of uterine cancer. From the same 
sources, I am satisfied, that although no temperament is exempted, 
yet that women of high colour and sanguineous constitution are most 
frequently its subjects. Mr. Lever has numerically proved this posi- 
tion. 

That the married are more prone to the malady than single women, 
and even than widows, does not admit of doubt. Mental distress, 
however the connexion of cause and effect may be explained, appears 
to me to favour its development ; and I think it might be proved, that 
its attacks are more rare in classes of society where pecuniary embar- 
rassment and its consequent anxieties are unfrequent. Although the 
data are yet incomplete, and therefore uncertain, it must, I fear, be 
assumed, that the disease is frequently hereditary. That uterine can- 
cer " runs in families," is a statement w T hose truth seems to be received 
without hesitation or inquiry. So far as the opinion shall prompt to 
a careful employment of prophylactic means, it can do no harm, but 
may perhaps be highly beneficial. I was lately informed, by a prac- 
titioner, on whose veracity I could fully rely, that he had seen, in a 
newly-born infant, malignant cancerous disease of the scrotum, the 
mother at the time being the subject of mammary carcinoma. 



I 
OF THE CERVIX AND OS UTERI. 271 

Insufficient food and clothing, especially during the inclemency of 
winter, unhealthy and exhausting occupations, and impure air, have 
been enumerated as predisposing causes ; but it may be fairly doubted 
whether they exert any specific predisposing influence. 

Exciting Causes. — That mechanical violence, as blows or falls, or 
long-continued and inordinate local pressure, may produce cancerous 
disease, seems to be almost incontrovertible. Hence it has been at- 
tempted to show, that the cervix uteri, from its exposure to injury in 
parturition and contusion in sexual intercourse, would of necessity be 
the most frequent seat of the disease, although virgins, spinsters, and 
widows, are frequent sufferers. 

Still we can scarcely suppose that these excitements do more than 
bring into activity the otherwise latent predisposition, seeing that in 
the vast majority of instances of blows or falls, or other physical in- 
juries, no such fearful result ensues. In uterine cancer it is unde- 
niable that many women attribute its first painful indications to mis- 
chief done during labour ; and yet so many instances occur in virgins, 
in women who have long been widows, and in those far advanced in 
life, where the natural use of the organ must almost have ceased, that 
we must admit such exciting causes with hesitation. Irritation and in- 
flammation may, and do certainly hasten the development of cancer in 
persons predisposed to it. I lately saw a case where probably, judg- 
ing from the previous good health, the disease would never have shown 
itself, had it not been for repeated inflammation of the cervix, produced 
by vicious sexual intercourse, and the frequent employment of highly 
stimulant injections, used to prevent conception. 

After all which can be adduced on the etiology of cancer of the 
uterus, it must be allowed, that in manj instances its presumed causes 
exist very long and with great intensity, without any subsequent ma- 
nifestation of the disease. Thus irritation and inflammation of the 
cervix produce simple induration, a state often mistaken for cancer, 
but easily distinguished from it by its inactivity alone : scirrhus having 
an inherent tendency to increase and grow, and to assimilate to 
its own nature any other structures which it may invade ; a power 
not belonging to simple induration. The converse of this opinion is 
equally true, viz., that some of the most formidable attacks of cancer 
have not been preceded by even one of its supposed causes. Indi- 
vidual predisposition must therefore be conceded ; but in what this pre- 
disposition really consists, whether in a particular condition of the 
-blood, or in some other undefined derangement of structure, is at pre- 
sent unknown. 

Pathology. — Opinions of this nature of cancer must vary in accor- 
dance with the more or less extensive views which may be adopted. 
If it be believed, that its materials exist in the blood, as well as in the 
component or molecular structure of organs, the locality only being 
undetermined, the affection must be without any other limit, than that 
which includes the entire organization. If, on the other hand, it be 
regarded as a disease of glandular structure exclusively, its ravages 
will be confined within narrower limits. 

By the disciples of Broussais, chronic inflammation is viewed as its 



272 ORGANIC DISEASES 

essential condition. By others it is limited entirely to the constitution, 
topical circumstances being considered not at all influential. It has 
been said to depend on depravation of the nervous fluid, on an en- 
larged and varicose condition of the veins ; and by Mr. Carmichael 
its origin has been ascribed to the generation of hydatids. These pe- 
culiar and exclusive views are certainly not calculated to inspire any 
confidence. Velpeau, Andral, Cruveilhier, Berard, and Carswell, are 
decided advocates, with certain modifications, of the cancerous vitia- 
tion of the blood itself; and there is no doubt, that carcinomatous 
and encephaloid matter has been found in the interior of both veins 
and arteries. I cannot, however, after a careful perusal of all the re- 
ported cases of this kind, discover any proof that these cancerous 
products exist in the blood or its vessels alone ; in other words, in- 
dependently of, or previously to the development of the disease in the 
tissue of the solids. Dr. Carswell does, notwithstanding, affirm, that 
the blood is the sole primary seat, and that he has seen cases, where 
the venous blood alone was contaminated by the disease. Such in- 
stances have not fallen within my observation ; and certainly, till the 
statement is supported by the fullest and most accurate records of 
the examples themselves, it will fail to command extensive assent. 
Dr. Hodgkin, without explaining the method of their origin, contends 
for the existence of compound serous cysts as the basis of malignant 
structure. There are numerous corroborative illustrations of this 
opinion in the museum of Guy's Hospital. Miiller, the celebrated 
German pathologist, has apparently established the fact, that the mi- 
croscopical elements of cancerous growths and their mode of propa- 
gation, are not only similar to the growth and arrangement of benig- 
nant tumours, but of the natural structure of the foetus. Hence he 
infers, that carcinoma is not a malignant or heterologous formation, 
forgetting, probably, as Dr. Walsh e acutely remarks, that such iden- 
tity simply shows that the heterologous character is produced not by 
the nature, but by the mode of combination and arrangement of the 
ultimate physical elements of the diseased growth. 

From all which has yet been observed and settled as true, it may, 
I think, be assumed, that the most frequent primary locality of cancer 
is not in blood, but in the molecular structure of organised tissues 
or parenchymata, and that the deposit of the morbid material is de- 
pendent on perverted nutrition or secretion. 

Diagnosis. — The distinction between malignant affections of the 
uterus, and those of simple character, is not always easily made. 
There are cases of engorgement, hypertrophy, and induration, in 
which the finger introduced into the vagina discovers an increase of 
volume, either in the entire uterus, the cervix, or in the body only. 
Now as these are changes induced by cancer, and as there may be 
slight or very severe pain in all the affections, it is important to point 
out the diagnostic characters. 

Simple engorgement, hypertrophy, and induration, are less hard, of 
more uniform surface, often unnaturally warm, and tender on pres- 
sure, whatever part may be affected ; while even in the early stages 



OF THE CERVIX AND OS UTERI. 273 

of cancer, the surface is irregular and rough, free from tenderness ; and 
there is often a weight, coldness, and stony induration. 

In cancer, and the simpler affections already mentioned, there is a 
marked difference in the mucous membrane, covering the cervix. In 
the former it is of a dull white, or slightly gray, colour ; in the latter, 
it is much redder and more vascular, and often morbidly sensitive. 

Hypertrophy, or common induration, may affect either the body or 
cervix separately, or at the same time ; but never in so isolated a form 
as to give rise to distinct and separated nodules of tuberculous indura- 
tion, like carcinoma. Scirrhus develops itself very slowly ; the former 
affections rapidly ; frequently reaching a size in six or eight weeks, 
which scirrhus would require as many months to attain. 

Single enlargements are generally easily cured by the means already 
pointed out ; while scirrhus, in its earliest formation, requires a much 
longer period. Common induration is nearly stationary. Malignant 
disease although slowly, is gradually progressive, and by affecting 
neighbouring tissues, transforms them ; and sooner or later, by their con- 
solidation, destroys the natural mobility of the uterus. 

When softening and breaking down have occurred in the cancerous 
mass, it may at first be mistaken for simple ulceration of the cervix, for 
corroding ulcer, or for chancre. The history, the symptoms, and above 
all, the touch and the speculum will remove every perplexity. The 
peculiarities of carcinoma ; its primary induration ; its affection of sur- 
rounding parts ; its fungoid growth in the seat of the ulceration ; its 
peculiar pain ; the accompanying immobility of the uterus ; the fcetor 
of the discharges; the hemorrhages; the cachexia and emaciation; 
with many other particulars too well understood to require any men- 
tion, will prove sufficiently diagnostic. 

Prognosis and Course of the Disease. — The exact prognosis depends 
very much on the stage of the disease, and on the belief of its cura- 
bility. Nor is it unimportant, however generally unfavourable may be 
the opinion, that it shall be most cautiously communicated. An abrupt 
expression, involving utter hopelessness of removal, would, in many 
instances, exasperate the malady, and by prostration of hope and energy 
hasten its progress. It is a disease capable of being arrested, if not 
cured, in its earliest periods ; and certainly, where the affection is not 
fully developed, so much has been done, and so much more may pro- 
bably be accomplished, that no idea of its being cancerous or incura- 
ble should escape the lips of the practitioner. And yet it must not be 
forgotten, that there are exceptions to the usual slow progress of scir- 
rhus uteri. In such, the topical induration is early and painful, hemor- 
rhages commence soon, softening and extension of the diseased growths 
are quickly evident, the general health decays ; and carcinomatous 
ulceration follows with unusual rapidity. It is clear in such instances 
there is no hope ; and our duties consist in soothing pain, and in af- 
fording every solacing alleviation. It would be difficult to mention 
with accuracy, the time which may elapse prior to a fatal termination. 
The assiduous early employment of prophylactic measures may, if it 
does not entirely arrest the malady, protract it through several years. 
The mean duration of uterine cancer is not as yet determined. Mr. 



274 ORGANIC DISEASES 

Lever thinks that it does not exceed twenty months ; and if this cal- 
culation include only the second or ulcerated stage, I concur in its 
general accuracy ; but it is certainly incorrect, if the early period be 
included. The final termination of cancer is sometimes exceedingly 
sudden and unexpected. Even before ulceration has commenced, and 
without any or severe pain having been suffered, the nutritive func- 
tions become impaired, the tissues grow soft and flaccid, and before 
there has been time for emaciation, the strength rapidly fails, and death 
occurs. In these cases, although the connexion between such effects, 
and the peculiar and deadly influence of malignant disease may not be 
satisfactorily established and defined, yet we can scarcely be deemed 
too credulous for believing in its existence. A similar observation is 
more true of advanced carcinoma. I lately treated a case with Mr. 
Coleby of the Borough, where the malignant ulceration commencing in 
the indurated deposit of the urethra, extended into the vagina ; the 
aggravated pain was greatly alleviated by belladonna and conium, used 
topically ; the appetite and health were so far improved, and the rav- 
ages of the disease so much checked for a considerable time, as to 
inspire the hope that a respite of at least many months might have 
been obtained. But just as these expectations were at their height, 
agonizing pain suddenly and inexplicably recurred, and the patient 
sank in less than a week. The possibility of similar events should not 
be excluded from even the most favourable prognosis. Temporary 
and partial failures of strength are by no means rare ; and whilst they 
demand vigorous, tonic, and stimulant treatment, need not excite the 
fears of the practitioner, except they are accompanied by greatly aggra- 
vated local pain. So far as my experience has extended, cancer of 
the uterus has certainly not been an invariably painful disease. I do 
not mean to deny, where pain does at all exist, that it is not generally 
at some period exceedingly severe ; the purport of my observation is 
to mark the fact, that there are cases throughout whose whole course 
there is scarcely any pain at all, and that in such opiates are rarely 
required. 

Prophylactic and curative -means to be employed in the early stage. — 
The curability of cancer has been, and still is, a subject of controversy 
which facts alone can determine. Extreme opinions are rarely true, 
and generally dangerous. A remark peculiarly applicable to uterine 
carcinoma. 

It has been already stated that scirrhous or hard tumours of the 
womb, are sometimes cured or become innocuous, by altered nutrition; 
the indurated mass being deprived of their softer, cellular tissue, and 
being converted into cartilaginous, cretaceous, or calcareous concre- 
tions. No reasoning can overturn facts ; and as preparations demon- 
strative of these fortunate changes exist in our museums, controversy 
and skepticism are thus far at an end. But it is not so with the sup- 
posed or real cures by surgical or medical treatment. Some reject all 
evidence of this kind, by prejudging the question controverted. If the 
disease has disappeared, it could not be cancer, because, according 
to them, cancer is a malignant affection never cured. Other writers 
hold a directly opposite theory. M. Bouillaud says, that he sees no 



OF THE CERVIX AND OS UTERI. 275 

difficulty in the cure of cancer, because erroneously enough he regards 
it merely as an inflammatory induration : and M. Breschet, adopting 
the fanciful notions of the illustrious Bichat, regards the disease as re- 
sulting from some error in the " organic sensibility," and believes that 
such a consequence is so unimportant, that it may be readily removed. 
The mean of such opinions will probably include the truth : and while 
1 believe, that confirmed carcinoma of the uterus has never been cured, 
either by partial ablation or by medicine, I cannot resist the conviction, 
that much may be done by a very early, well-sustained, and untiring 
prophylactic management. But before entering fully on the treatment, 
it may not be without advantage to describe, as accurately as possible, 
those topical conditions of the uterus which alone justify the belief, 
that the disease is still in its incipient state, and therefore within the 
reach of curative measures. 

The muciparous glands, in the interior of the cervix, may be hard, 
and of the size of small shot, and pressure on them may induce pain, 
and yet, if the mucous membrane covering them be not ulcerated, a 
restoration to a healthy state, may, by proper treatment, be fairly 
hoped for. I am aware that, in a slight degree, such a state of the 
muciparous glands may occasionally exist, as the result of irritation, 
induced by various causes, as painful and excessive intercourse, dys- 
menorrhea, &c. ; but the effect is then generally transient, and unaccom- 
panied by the more permanent symptoms already mentioned. These 
little indurated glands are often associated with a hard and fissured 
state of the os, and an enlarged and hard cervix. The turgescence of 
the interior of the neck, and its deep flesh-colour, both within and ex- 
ternally, are well marked. The uterus is usually increased in bulk, and 
feels altogether thicker and more solid. 

If the vagina is at all knotted and indurated ; if the cervix is united 
to the vagina by hardened mucous membrane, and cannot be moved 
freely ; if the uterus generally is fixed and consolidated with the 
neighbouring organs, or if there be abrasion, or softening, or commen- 
cing ulceration ; then the case wears a very unfavourable, but not an 
entirely hopeless aspect, and a most cautious prognosis must be given. 

This first stage is often very slow, and it is one of its accompanying 
evils, that a long period must elapse, even where the treatment is suc- 
cessful, before it is possible to give a decidedly favourable prognosis 
It is unfortunate that the symptoms of this incipient state are so slight ; 
were they more severe, earlier attention would be secured. The pains 
are not constant ; the appetite, digestion, and sleep are not much in- 
terfered with ; and therefore the affection is disregarded. But after 
a time, intercourse becomes painful, being often followed by a discharge 
of blood (lasting sometimes only for an hour or two ; at others, a slight 
draining will continue for the following day) ; there is more constant 
or periodical uneasiness centrally in the pelvis, irritability of bladder, 
and failure of general health. These symptoms excite apprehension, 
and lead to the discovery of the disease. 

, Prior to the commencement of treatment, the patient should be con- 
vinced that self-denial must be long practised ; that her diet is to con- 
sist exclusively of simple nutritious and non-stimulant materials; that 



276 ORGANIC DISEASES 

she must abstain from sexual intercourse, and maintain long and con- 
stantly, or nearly so, the recumbent posture, and be especially cautious 
to avoid mental emotion and effort ; physical exertion being entirely 
forbidden. 

It must never be forgotten, that the object of all treatment in uterine 
cancer is, first, to prevent excitement and irritation, the almost cer- 
tain forerunners of progressive advancement ; second, by topical reme- 
dies, applied directly to the diseased parts to arrest further develop- 
ment of the poison, and to destroy or neutralize that which already 
exists ; and, third, to sustain and augment the vigour of the system, by 
judicious attention to the digestive functions, and by suitable diet, pure 
air, and regulated exercise. I need scarcely urge especial attention 
in the early stage to the local treatment ; it is here that great recent 
improvement has taken place. 

Repose. — Rest in the recumbent posture is absolutely indispensable. 
Not in bed, except during the cold of winter, when its efficacy is much 
increased by the higher temperature. A well-stuffed couch should be 
chosen, and to this the patient should be strictly confined. If the 
apartments will permit it, she may be wheeled about, or if there are 
grounds contiguous to the house, she may, during fine and warm wea- 
ther, be drawn around them. I despair of advantage from any treat- 
ment, where this point is not fully secured. Still there are exceptions 
even to this rule ; and where digestion is seriously impaired by abso- 
lute rest, where constipation ensues, where amenorrhoea, nervousness, 
and want of sleep are its consequences, some modified plan must be 
adopted. N 

Ji simple and unstimulating diet is essential, especially where strict 
repose is enjoined. Wine and spirituous liquors are to be interdicted, 
except when medically ordered ; animal food once daily, and in some 
instances on alternate days, is sufficient. Without this scrupulous at- 
tention to diet, dyspepsia and congestion of the various viscera will 
occur. Mild ale or porter may be allowed, and an occasional draught 
of hot water after a meal or before going to bed, will aid digestion and 
induce sleep. Milk in any form is excellent, where it agrees. Cheer- 
ful society and a happy mind are of great moment. 

Dr. Montgomery says, " except there be something specially to for- 
bid its use, mercury should be given, so as to bring the system very 
gently, but decidedly under its influence ; for which purpose it may be 
combined with iodine in very minute proportions, with camphor, opium, 
hyoscyamus, or hemlock." By a reference to pages 65 and 88, it 
will be seen, that I have long entertained similar views of the remedial 
power of this invaluable remedy. Still, if the disease has advanced 
beyond the first stage, if there be a predominant irritability or tendency 
to phthisis or struma, it ought not to be administered. Several of the 
cases scattered throughout the book, will demonstrate its value, where 
the cervix has become thickened and indurated. 

Abstinence from food has been strongly recommended, and cases 
have been recorded where reputed cures were effected by living for 
long periods on iced water. Ponteau and Mr. Pearson have adduced 
such. But it must be remembered, that irritability is not an unfrequent 



OF THE CERVIX AND OS UTERI. 277 

consequence of anseraia ; and few women could endure such abstinence 
without its occurrence, associated probably with alarming exhaustion. 
There can however be no doubt, that much may be effected by a 
strictly regulated diet. The propriety of s^ x t^l abstinence has been 
generally and very properly insisted on. Dr . i3eattie, however, thinks 
that the disease runs on more rapidly to a fatal termination, where the 
husband and wife have been separated, than where they have been al- 
lowed to continue together. Such are probably very rare and excep- 
tional instances, as no other writer seems to have arrived at similar 
conclusions. 

Formerly certain medicines, by altering the condition of the blood, 
were believed to be curative. Amongst these, conium enjoyed the 
highest celebrity, while belladonna, stramonium, hyoscyamus, aconitum, 
and some others, although less relied on, were still of repute. Of all, 
it is enough to say, that cancer has never been cured by them; and 
the most they have probably accomplished, is the relief and mitiga- 
tion of the attendant pain by their sedative properties. These drugs, 
however, and especially iodine, mercury, and iron, should form a part 
of the treatment. Of iodine and mercury I have already spoken ; and 
certainly, chalybeates, either as natural waters or artificially prepared 
salts, accomplish a vast amount of good. The iodide of iron I have 
exhibited, in combination with the ioduret of arsenic and conium. In 
one case especially, topical treatment also having been employed, a 
cervix with several tubercular deposits in its structure, apparently 
yielded to its powers ; the tumours themselves, of scirrhous hardness, 
softening and becoming absorbed, instead of passing into the ulcerative 
stage. There is no reason why the external use of iron should not be 
combined with the internal ; and I have known some instances, where 
very suspicious appearances of the lips and tongue have been cured 
by the local application, and internal use, of the sesquioxide of iron. 
Almost any of the preparations of this invaluable remedy may be 
either dissolved or made into a paste with water, and topically ap- 
plied. Collating the opinions of others resting on cases, with the facts 
observed by myself, I am convinced that mercury and iodine, aided 
by iron and the horizontal position, are the best general remedies. 
But in cancer of the cervix uteri, even these are not to be relied on 
alone : external or local treatment must be employed. 

Local Remedies. — Blood-letting, in some instances by venesection, 
but most frequently by cupping, and leeches applied to the perinseum, 
vulva, or cervix uteri, or by scarifications of this latter part, has long 
ranked amongst the most efficient means for diminishing the size, and 
arresting the advance of cancerous growths. M. Lisfranc says, "that 
local bleeding, however copious, determines new congestions toward 
parenchymatous organs ;" and that if we hope to produce any anti- 
phlogistic effect by leeches, they must be applied in very great num- 
bers, and should be preceded by at least one general bleeding. Val- 
salva, Fearon, Begin, Montgomery, and almost every writer with the 
exception of Lisfranc, are agreed on the utility of the local abstraction 
of blood. Doubtless leeches should be used in the early stages of carci- 
noma uteri, and in sufficient numbers to empty the vessels, otherwise 



278 ORGANIC DISEASES 

increased congestion may be the result. Nor is it improbable that in 
some cases, particularly where the tubercular deposit is closely adhe- 
rent to the skin, that their use may be precluded by the dread of ulcer- 
ation following the bites. Every one, under such circumstances, will 
fear the development o/ cancerous softenings and degeneration. Still 
allowing their fair weight to these disparagements, there can be no 
doubt that capillary depletion is highly valuable, not only by diminish- 
ing pain and congestion in the diseased part, but also by relieving in- 
flammation and congestion in neighbouring tissues. As already ob- 
served, M. Lisfranc's prejudices must not be permitted to negative a 
treatment, almost invariably valuable. I have seen cases, where pa- 
tients were so convinced of the utility of leeches from the diminution 
of uterine pain, weight, and general pelvic uneasiness, as to urge their 
frequent use. Nor can there be any doubt, that mercury or iodine, 
and baths and fomentations, will be more efficient where local deple- 
tion has been previously employed. The repetition of the local bleed- 
ing will be regulated by the estimate of the benefit; nor in any case 
should it be carried further, especially where a large quantity of blood 
is abstracted by cupping, than the powers of the patient fully justify. 
I have seen prostration induced by a disregard of this precaution, and 
I have been convinced that the disease subsequently advanced more 
rapidly. In many instances I have advantageously ordered leeches 
to the cervix, varying in number, from three to eight, once every 
seven or ten days, enjoining the hip-bath immediately afterwards. It 
is always, I think, to be regretted, when any circumstances interfere 
with their use. 

Baths. — There are few practitioners who doubt the utility of warm 
baths, in the first stage of uterine cancer. Lisfranc says, " they attract 
the blood towards the pelvis (vide Lectures in the Lancet, November, 
1833), which, where there is a disease of the pelvic organs, we should 
avoid. ,; He instances the effect produced by them in bringing on 
menstruation when arrested, and incorrectly remarks, that after their 
use patients almost always complain of greater pain and weight about 
the pelvis. 

Such complaints I have scarcely ever heard, and M. Lisfranc must 
surely forget, that the bath and previous leeching or scarifications, are 
to relieve a congestion already present ; for he cannot be ignorant, that 
the form of amenorrhcea to which he refers, and the pain and tension 
of the cervix in cancer, must frequently depend on this identical con- 
gestion, to relieve which topical blood-letting and the hip-bath are so 
successfully used. Let it, however, be understood, that the patient 
must remain in the bath at least an hour night and morning, and some- 
times even for a longer period. The bustle and hurry of a bath, when 
used only for a few minutes, excite and do harm, by inducing irritation 
and syncope. Its calming, sudorific, and sedative effects,' cannot be 
realized in less than an hour or an hour and a half. Nevertheless, 
there are women so susceptible, so prone to faint, whose digestive or- 
gans are so easily deranged, and their appetite destroyed, that the 
bath cannot be used. Often have I heard patients declare, that they 
owed their sleep, and freedom from pain, to the regularly repeated 



OF THE CERVIX AND OS UTERI. 279 

nightly bath. If chilness, faintness, sickness, increased leucorrhcea, 
diarrhoea, or prostration of strength ensue, then it must be given up. 
The soothing effect of the bath is certainly increased by admitting the 
warm water into as complete contact as possible with the vagina and 
os uteri ; a point easily accomplished by a common speculum tube of 
the proper size, perforated with numerous holes at its sides, which the 
patient soon learns to introduce for herself. 

At what time, it may be asked, are blisters and setons, and the topi- 
cal use of iodine, the chlorides of zinc and mercury, and nitrate of silver, to 
be commenced ? I think these local remedies will be most efficiently 
used, when by depletion, the hip-bath, a regulated diet, the recumbent 
posture and mild aperients, the congestion and general induration of 
the cervix have been diminished, and when the muciparous glands 
have lost some of that shot-like or gravelly hardness already described. 

Let it also be remembered, that in this stage there is no disease of 
the upper portion of the vagina, no consolidation of this canal with the 
uterus, nor of the uterus with the neighbouring viscera : but the affec- 
tion appears to be entirely limited to the cervix. It is important to 
remember that this is the only curable condition. If the malady has 
advanced so far as to have implicated other structures, it will scarcely 
be reached by remedies either of a constitutional or topical kind. It 
must, too, be understood, that no part of the plan can be safely neg- 
lected ; not a few only, but many weeks are required fully to carry 
out a treatment, whose efficacy must be tested rather by the disease 
not getting worse, than by any rapid amendment. If, however, there 
be a slight improvement, if the cervix loses its defined hardness, 
whether of the muciparous glands or of its more general structure, it 
may be assumed, that the affection is progressing towards a cure, and 
that however distant, the period of entire removal will come. 

Iodine. — So far as my experience has gone, the external application 
of this drug to the cervix is sufficient to secure its beneficial effects, 
especially when the friction is persevered in for ten or twelve minutes. 
Many patients apply it by the finger, others employ a camel-hair pen- 
cil or sponge, mounted on a slender piece of cane. If the iodine be 
given by the stomach, vertigo, excitement, irritability, and occasion- 
ally bleeding from the nose or mucous lining of the trachea, are more 
frequently and quickly produced, than when the remedy is used by in- 
unction. Even in the latter method, after a few weeks, the iodine 
rarely fails to give rise to these peculiar effects. The ointment I use 
is the following: — 

* 

B. Iodin. pur. gr. xv. Potassse Hydriodat. ^ij. Unguent. Cetacei. giss. 
M. ft. Ung. : nocte quaque infricand. 

A portion of the ointment, about the size of a small nutmeg, is to be 
introduced into the vagina, and rubbed into the affected cervix every 
night. When the symptoms already described shall occur, the remedy 
must be given up for a week, ten days, or a fortnight, during which 
intervals, aperients of magnesia, tonics, and nutritious diet, should be 
employed. 

The average time, in which I have seen resolution of the induration 



280 ORGANIC DISEASES 

accomplished, varies from eight or ten, to sixteen or twenty weeks ; 
this even greatly depending on the diligence and susceptibility of the 
patient. It may, however, be remarked, that while there are many 
individuals incapable of receiving the impression of mercury, there are 
very few on whom iodine will not exert its accustomed influence. 

Nitrate of Silver. — I have found this caustic most useful where the 
mucous tissue, lining the channel of the cervix, or around the margin 
of the os, has been red and tender, or where there have been obvious 
or slight ulcerations, or a tendency to softening. The character of the 
mucous membrane has generally improved after three or four applica- 
tions; and in a case I am now attending, the very unhealthy surface 
of an indurated cervix, and its attendant and excessive leucorrhcea, 
have been cured by its employment. It must be repeatedly used where 
there is a fear of ulceration, or where, from the fcetor of the discharges, 
and the increased pain and unhealthy aspect of the surface, the dis- 
ease seems likely to make rapid progress. Severe pain is not often 
complained of, not even where the solid nitrate is rubbed over the part. 
Frequently, however, where the patient has suffered pain before, the 
nitrate has entirely removed it, and I can speak most confidently of the 
advantage of repeatedly obtaining a new surface from its use. The 
following is a sufficiently strong lotion : — 

R. Argenti Nitratis, 9iss. ad 9ij. 
Aqua destill. £iv. M. ft. Lotio. 

It is scarcely necessary to remark, that the speculum must be intro- 
duced, in order to apply topical remedies with the exactness which 
they require. 

Even the most skeptical must allow, that there is nothing negative 
about the treatment here enjoined; nor will it be denied, if it be not 
beneficial, that it need do no harm. Thus, while on the one hand it 
can be proved that great good has arisen from the judicious trial of 
these means, it may on the other be demonstrated, that where tbey 
have failed, the affection was too far advanced before they were em- 
ployed. An additional inducement to adopt such treatment, is the cer- 
tainty, although in some instances very slow, where the disease is left 
to itself, of a fatal result. At all events, it is a matter for congratula- 
tion, that any stage of cancer of the womb should, on sufficient grounds, 
be thought to be curable ; and it is the least which can be expected for 
such an opinion, that practitioners of medicine shall weigh and test the 
accuracy of the pathology, and the value of the means believed to be 
thus beneficial. The appended cases will throw additional light on 
the subject of the chapter. 



Case 61. 

reported bt mr. henry oldham. 

Elizabeth — — — , aged 49, a woman of ordinary stature, with dark hair and eyes. 
She is married ; is the mother of six children ; and has had two miscarriages. She 
began to menstruate at 13 years of age. Amenorrhoea was induced from wet feet, 
after the third period, and this condition existed for the space of five years. During 



OF THE CERVIX AND OS UTERI. 281 

this interval, she endured the most aggravated sufferings : she appears to have passed 
through the successive stages of the simple, severe, and confirmed chlorosis ; and when 
in this latter state, her friends aptly compared her to a "walking ghost." This af- 
fection gave rise to, and became complicated with, insanity, which continued for three 
weeks, being preceded by severe headache, and other symptoms of cerebral excitement. 
This was relieved by a discharge from the ears and nose, of a yellow colour, and very 
fetid. This chlorotic condition was eventually cured by the re-establishment of the 
catamenia. From this time, till within the last twelve months, she has regularly ob- 
served the accustomed periods. Her age indicates that the catamenia are about to 
cease ; and the history of her symptoms, during the last year, confirms this opinion. 
The menses have been very irregular, both in quantity, quality, and time of recur- 
rence. A profuse leueorrhcea alternates with the catamenia! flow. 

On admission, she complained of lumbar pain, central pains in the lower abdomen, 
of a pricking and shooting character, which have existed during the last three or 
f-iur months. An offensive muco-sanguineous discharge (being the catamenia mixed 
with leueorrhcea) flows from the vagina; the constitutional symptoms are slight. 

On examination — k * The mucous lining of the upper part of the vagina is relaxed 
and hot ; and above this a hard body is felt, occupying the superior part of the cer- 
vix, and the lower portion of the posterior paries of the uterus. The os is hardened 
and fissured." 

After a short preliminary constitutional treatment, and the maintenance of the re- 
cumbent position, she was ordered 

Julepum Iodinse, ter die 

Unguenti Iodinas, instar nucis Moschatse massa, tumori diligenter nocte 
maneque infricanda. 

This course was adopted on the 2d of June; and at the commencement of August, 
all appearance of the tumour, and the unhealthy condition of the os, had disap- 
peared ; and she left the hospital cured. 



Case 62. 
reported by mr. trenery. 

Jane , aged 25, was admitted into Mary's Ward, September 5, 1835. She 

is the mother of three children, the last of whom was born three months since. Her 
labours have been undeviatingly easy, and her general health uniformly good. Since 
her last confinement, the abdomen has been considerably distended ; and occasions 
great suffering when pressed. This enlargement is the result of an accumulation 
of flatus. In addition to this tympanitic condition, which is associated with impaired 
appetite, occasional nausea, and constipated bowels, she complains of a sense of 
weight and bearing down in the lower abdomen, which is aggravated by the erect 
posture or by walking. 

After an examination, Dr. Ashwell reported :— 

"I find a tumour of scirrhous hardness situated low down, on the posterior part of 
the cervix of the uterus, t>ut not implicating the lip. This growth presses on the rec- 
um, and thus accounts for the constipation." 

After the use of an assafcetida injection, with the internal administration of tonics 
to diminish the size of the abdomen and improve the constitutional power, she was' 
ordered to take the julepum iodinas three times a-day, with the topical application of 
the unguentum iodinae. A small portion of the ointment, about the size of a nutmeg- 
was to be passed up the vagina by the nurse, and rubbed over the tumour. {She con- 
tinued pursuing this plan, with occasional intermissions, till October the 24th ; when 
on examination instituted by Dr. Ashwell, it was found that " no vestige of 'the tu! 
raour was present, and that the os and cervix were perfectly healthy." ^Durino- this" 
'interval, her symptoms were those arising from the mechanical pressure of the tu- 
mour, which gradually subsided with its resolution. 



282 ORGANIC DISEASES 



Case 63. 
reported by the clinical clerk. 

Sarah , aged 32, a woman of middling stature, fair and delicate complexion, 

with light-brown hair, was admitted into Mary's Ward on the 24th of January, 1835. 
She is°a married woman, and the mother of two children, the youngest of whom i3 
-thirteen months old. Her health has been uniformly good. Some short time pre- 
vious to her marriage, which took place five years ago, and subsequent to that period, 
she has had leucorrhceal discharge. The catarnenia, too, from the same period, have 
been profuse in quantity, frequent in their recurrence, and long in their duration, 
usually appearing every three weeks, and lasting for eight days. This excess of 
secretion continued two years before its effects were visible on the general health. 
Since this time she has suffered constantly from languor and lumbar pains. Her 
last confinement, thirteen months since, was followed by the establishment of an ex- 
cessive red discharge, apparently of a passive hemorrhage, which reduced her constitu- 
tional power, and engendered debility with loss of flesh. 

A slight increase, at the lower part of the abdomen, with three months' suppression 
of the catarnenia, had induced the belief that she was pregnant. This supposition 
was confirmed by her experiencing sensations analogous to those she had noticed in 
her previous pregnancies. She was dispossessed of the idea, however, by the ap- 
pearance of the catarnenia a fortnight ago; on the accession of which, the abdomen 
resumed its natural size, and the mammae, which had become tense and rounded, shrunk 
into a flaccid condition. The leucorrhceal secretion has relaxed the vagina. 

Jan. 26. — After an examination, Dr. Ashwell made the following report: — 

"The uterus is enlarged generally; its lips and cervix are swollen and soft; and 
there is considerable quantity of leucorrhceal secretion bathing the parts posteriorly. 
Just above, and encroaching on the cervix, at the posterior part of the uterus is a tu- 
mour about the size of a hen's-egg, scarcely hard enough for scirrhus." — Ordered, 
&. lodinee purse gr. xij. Potassse Hydriod. 3ij. Adip. 5iss. fiat unguen- 
tum. — Infricetur massa instar nucis Moschatse super tumorem nocte 
maneque. 
Julep. Iodin. cum Vin. Ferri 53. ter die sumend. 

The tumour, by pressing on the rectum, is the occasion of constipation ; and pro- 
lapse of the gut ensues in the attempt to evacuate the faeces. She complains of a 
dragging sensation at the loins, with pain at the lower part of the abdomen ; but it 
is not severer than what usually coexists with the performance of the menstrual 
function. 

She continued to pursue this plan of treatment for six weeks, omitting the appli- 
cation of the iodine during the catamenial flow. On an examination being instituted 
after the expiration of this time, the tumour on the posterior paries of the uterus had 
disappeared. The use of the iodine was unattended with any deleterious effects. 
She had assumed a more healthy and robust, rather than an emaciated appearance; 
and, during its exhibition, she did not complain of headache or undue cerebral ex- 
citement. 



Case 64. 

REPORTED BY MR. TWEEDIE. 

Elizabeth , aged 46, was admitted as an out-patient of Dr. Ashwell, in the 

early part of 1833. She has borne several children, and till lately has enjoyed good 
health. For the last few months, however, there has been vaginal discharge, of a 
muco-purulent, and occasionally of a sanguineous character. She suffers much from 
central pains, especially from pain deep down behind the pubes; her appearance is 
cachectic and unhealthy ; the catarnenia are irregular. 

On examination, the cervix was found excessively hard and enlarged, without any 



OF THE CERVIX AND OS UTERI. 283 

distinct deposit of hard material ; the edges of the os puckered and uneven, and their 
surface slightly broken; ulceration appears to be just commencing. 

Sumat Julep. Iodinee, Sj. ter die.-— Utatur Ung. Iodime, more solito. 

This case continued under treatment for nearly twelve months ; but as it was only 
one out of many similar examples, there was no accurate note preserved of its pro- 
gress towards cure; nor would it have been reported at all, if the patient had not 
accidentally presented herself, in November, 1835, in the out-patients' room; and 
thus afforded to Mr. Tweedie, who originally had charge of the case, and to myself 
the opportunity of carefully examining the os and cervix. ' 

'AH vestiges of induration, puckering, irregularity, and abrasion of surface have 
disappeared: and with the exception of a leucorrhceal discharge, the parts m'av be 
pronounced entirely healthy. 

I have seen this patient very lately, and I can still report the parts to be as sound 
as they were when the treatment was first discontinued. 

Case 65. 

For this and the following Cases, I am indebted to Dr. Montgo- 
mery. 

Mrs. S. I saw this lady at the request of Mr. T. Burke of Camden-street, on the 
24th August, 1833. She was in her 47th year, had had six children, and had en- 
countered much domestic anxiety. She was suffering severe pain, for the last nine 
months, in the region of the uterus, in the small of the back, and down the thighs 
with occasional profuse hemorrhages, alternating with sern-mucous discharges A 
vaginal examination detected well-marked morbid alterations in the uterus the ori- 
fice of which was irregularly notched, tumid, and with several nodules of scirrhous 
hardness projecting all around its margin ; and the posterior wall of the cervix was 
so much thickened, that, when felt from the rectum, there was a distinct prominence 
or the part, with very painful sensibility; she had lost her appetite, was losing her 
flesh, got little or no sleep, and was in great distress of mind, about the state of her 
health. 

The treatment was commenced by leeching, and the use, both internally and ex- 
ternally, of hydnodate of potash and iodine, and of anodynes; subsequently the 
symptoms not yielding, her system was brought moderately under the influence of 
mercury, and so kept for some time ; lastly, she took carbonate of iron with hyoscva- 
rnus and conium ; counter-irritants were used ; the leeching was frequently repeated ■ 
the hip-bath was tried, but it so decidedly made her worse each time, that it was 
given up. After several months of continued treatment, she was perfectly cured of 
the uterine affection, and has now been well for more than seven years 

Atone time, during the earlier part of her treatment, this patient suffered much 
from increase of volume in the breasts, which became, at the same time, excessively 
painful, and exhibited a remarkable change in the condition of the areola 

Mr. B— this day, Nov. 29, 1841, informs me that the healthy condition of 

the uterus was ascertained by him, the day before yesterday. 



Case 66. 
reported by dr. montgomery. 

Mrs. B— , aged about 35 years, is a member of a family amongst whom 

there has been a very extraordinary predisposition to cancerous affections! she has 
had three children, and one of her labours was severe. When I first saw her which 
was in May, 1837, she complained of lancinating pains in the loins, back and'thiffhs, 
dysuna, bearing down, with irregular sanguineous and other discharo-es; and° on 
examination, the os uteri was tumid, uneven, gaping a little, with its matins irregu- 
larly nodulated, and, in one spot, there was a deep cleft, as if the part had" been torn • 
there was no discoverable increase in the volume of the uterus, nor any consolida- 



284 ORGANIC DISEASES 

r 
tion of it with the surrounding parts. She was put, gently, under the influence of 
mercury, and afterwards, treated with iodine and iron, baths, &c, under which plan, 
the symptoms were completely relieved for several months; but on feeptember loth, 
1838, my attendance was again required, and I found all the former symptoms had re- 
turned with increased severity ; and on examining the os uteri, its condition was more 
unfavourable than on the former occasion ; the nodules had become harder and more 
prominent, and the whole of the lower part of the cervix had increased in size, and was 
much congested with blood ; there was, also, a tumour apparently of the ovary, in the 
ricrht iliac hollow where there was considerable tenderness; leeches were now ap- 
ofied directly to the os uteri; and she was put under the use of mercury in altera- 
tive doses, but not so as to induce its specific action on the system. 1 he leeching 
was repeated, both internally and externally, and then iodine was given, and after- 
wards iron for several weeks, with occasional applications of counter-irritants. 

On the 23d October, the note of her case was, "ovarian tumour much diminished 
and the tenderness almost all gone ; the cervix uteri less engorged, but tubercles stil 
hard and prominent, but not so sensitive, and she suffers less pain; has menstruated 
once quite regularly, while taking the small doses of mercury;" the specific action 
of this remedy was now induced by blue pill, with iodine and extract of opium, and 
kept up for some weeks, being accompanied by leeching, baths, &c, and tollowed, 
as already stated, by the use of iron, iodine, and other means, as occasion appeared 
to require, and the result was the complete removal of the complaint ; and 1 am now 
informed, by her medical attendant from the country, that she continues pertectly 

In' another case Dr. Montgomery says, on examination. " I found a fulness in the 
left iliac hollow, with considerable tenderness on pressure; but I could not detect 
any defined tumour. The os uteri was irregular in its form ; its margins hard, and 
rendered very uneven by the projection of several well-defined small nodules, having 
all the firmness of true scirrhus,and very sensitive to pressure, which she said drove 
the pain out through her back, into her left side and thigh, and up to her stomach, 
o-ivino- her a sensation as if she were about to vomit, or retch. The lower part ot 
the cervix uteri was a little increased in volume, and, when seen through the specu- 
lum, was almost purple from vascular congestion, and the temperature of the part 
was decidedly above the natural standard. 

"The treatment adopted was very nearly the same as that of the last case. 
Leeches were applied to the os uteri, and over the left side, where a small blister 
was kept open for several days, and on two or three occasions, other counter-irritants 
were also applied, and the system was brought, gently, under the influence ot mer- 
cury, and so kept for some weeks ; afterwards, iron and iodine were used, by fric- 
tion and internal use, with warm baths, tonics, &c. 

"There was such a decided amendment by January, that she went home, and the 
treatment was directed by letter till April, 1839, when she came to town, and I 
found the os uteri almost restored to its healthy state; and, six months afterwards, it 
was completely so, and still continues, of which 1 satisfied myself while writing these 
observations, November, 1841." i 

One other case, in which the symptoms were well markeo, I shall only reter to, 
for the purpose of mentioning, that since the removal of the affection, the lady has 
borne three children. . 

Having had several opportunities of knowing, that cancerous artections ot tne 
uterus do not prevent conception, which supplies fuel to the flame already kindled, I 
think abstinence from connubial intercourse cannot be too strongly insisted on, until 
full time shall have elapsed to allow of the adoption of efficient treatment, not only 
for the removal of the morbid organic condition of the organ, but also, tor the subsi- 
dence of the increased irritative susceptibility which must remain after such alte- 
ration. _ - , 

Early in 1839, I saw a lady, aged about 40, from the North, who had been, more 
than two years, labouring under this disease, during which time she had been preg- 
nant and prematurely delivered, and was again so, a second time, when she came to 
town to consult, me. Each time, pregnancy was followed by a great increase of her 
sufferings, and when that period arrived, at which distention at the lower half of the 
cervix began, the irritation became so great, that labour was prematurely excited. I 
understand she has been pregnant a third time with the same result. 



OF THE CERVIX AND OS UTERI. 285 

§ 
In October, of the same year, I saw, in consultation with Dr. Apjohn, another lady, 

from the West, in whom this condition had evidently existed for some months, and 

who after submitting to treatment, for a short time, in town, became pregnant, soon 

after her return to the country, and went to her full time. 

My friend Dr. White, of Knock, county Clare, under whose care this lady has 

long been, has just sent me an account of her progress, which, as containing many 

particulars of interest, I shall give in his own words. 

" Thornberry, Knock, Dec. 1st, 1841. 

•'When Mrs. — left Dublin (about two years since) she continued, for about 

three months, as you then saw her, after which she became pregnant; during the 
earlier part of her pregnancy, she appeared to get better in health, except that the lan- 
cinating pains continued, and for the last two months her legs became numbed, and 
she was unable to walk; at the time of her delivery, 1 could feel the riyht ovary 
enlarged and uneven, the os uteri was thickened, hard, and uneven, and there was 
considerable hemorrhage, which continued for some hours in consequence of the im- 
perfect contraction of the uterus; since then (now a year), she has been gradually 
growing worse, the menses having appeared regularly, but more profuse than natu- 
ral, and there has been constant fluor albus; for the last month, the discharge has 
become, sometimes, very abundant, sanious, and offensive, at other times, it is ichorous, 
with a yellowish tinge, the os uteri is patulous and hard, and there is considerable 
tenderness in the hypogastrium, particularly at the right side; the legs are quite 
paralysed, she is, almost entirely, confined to bed, and the pain is very violent; for 
the last two months, she has had a constant spitting of thick mucus, which is very 
distressing; the right ovary can be felt through the integuments, but has not increased 
in size, for the last year, but 1 think the uterus has; as to the treatment, it has been 
latterly, chiefly with a view to relieve suffering; no plan of treatment that has been, 
as yet, tried with her, appears to have any useful effect. 

" Very sincerely yours, 

" Henry White." 

In cases where there is abrasion or softening of the cervix, with 
increased sensibility and adjoining induration, I have used the strong 
solution of nitrate of silver as an erodent (30 or 40 grains of the salt to 
3iv. of distilled water), with marked benefit. It is best applied with a 
speculum : the lips of the os and the channel of the cervix, as well as 
its external membrane, are thus brought into view, and the solution or 
the solid cylinder of the nitrate may then be accurately smeared oyer 
the affected parts ; either by a hair pencil or by tow, fastened to the 
end of a piece of cane. This caustic rarely produces much, or lasting 
pain. It is quickly decomposed by its contact with the fleshy cervix ; 
the oxide of silver remaining on the surface, and assuming a black or 
dark-blue colour. Usually, the eschar is detached about the third or 
fourth day, being thrown off in shreddy films : when the abraded sur- 
face will generally have acquired a much redder, and healthier aspect. 
The caustic should be early repeated ; and if after the fresh eschar, 
there is still further topical improvement, the treatment should be per- 
severed in, and a hopeful prognosis may be cautiously given. Often, 
after these renewed applications, extending over many weeks, and 
aided by the Lotio Nigra, or the Oxide of Zinc, I have healed abra- 
sions, and commencing ulcerations of the os and cervix. The accu- 
racy with which any erodent substances may be applied through the 
speculum, and the little pain and exposure attendant on its introduction, 
give to it a peculiar and increasing value. The glass specula now 
made, are especially useful, as the caustic spoils the polished surface 
19 



286 ORGANIC DISEASES 

ft 

of the metal instrument. On the glass it exerts no chemical action, 
and is easily washed off. 

Of the Bichloride or Oxymuriate of Mercury, I am somewhat afraid, 
as it causes much pain, local heat, tension, and inflammation. On 
two occasions, where I thought I had used it sufficiently carefully, in 
addition to the above inconveniences, it produced slight symptoms of 
poisoning and tenderness of the gums. In a granulated condition of 
the cervix, accompanied with partial and suspicious indurations and 
fetid discharges, I once employed the Chloride of Zinc ; but as the pain 
was severe and protracted, and the eschar was seven or eight days 
in separating, and as the surface was not more improved than I had 
often seen where the lunar caustic had been used, I have not again 
resorted to it. Of Arsenic, Sulphate of Copper, and Nitrate of Mercury, 
I have no experience. I have never witnessed the effect on a diseased 
cervix of the actual cautery, nor can I think it would be more perma- 
nently beneficial than the potential erodents. The proximity of the 
part to the bladder, urethra, rectum, and vagina, would seem, inde- 
pendently of other considerations, to forbid its use : excepting it were 
undeniably proved, that the resulting inflammation and suppuration 
were of far healthier character, and attended by results far more per- 
manent than can be obtained in any other way. Notwithstanding that 
it may, perhaps, be found, that the actual cautery alters more con- 
siderably than any other caustic the vital condition of surrounding 
tissues, and effects greater changes in the subsequent capillary circu- 
lation, I feel persuaded it will never be more than very partially used 
in this country, for diseases of the uterus, suspected to be malignant. 

In conclusion, I would caution practitioners against the too common 
error of at once determining an ulceration of the cervix to be malig- 
nant, because it may coexist, with doubtful hemorrhages, induration, 
and other suspicious symptoms. I know this is controversial ground, 
and with those who have long regarded every protracted hardness of 
this part as sure to result in cancer, it will be difficult to produce a 
contrary impression. With truth I can affirm, that such an opinion 
may in some, if not in many instances be safely abandoned, and a 
more favourable one entertained. But, allowing more than I am dis- 
posed to concede on this point, the possibility, that such a change 
may not be cancerous ; or if so, that its progress may, in this early 
stage, be arrested, and the patient saved from the full development of 
an incurable, lingering, and agonizing disease, are certainly events 
sufficient to insure the fullest trial of the treatment now enjoined. 

OF THE ADVANCED STAGE OF CANCER. 

History and Symptoms. — It may be assumed as a fact, with scarcely 
any exception, where the treatment already enjoined has failed, that 
sooner or later, without any special cause, although often hastened by 
local irritation or injury, the induration of cancer will gradually pass 
into the stages of softening, suppuration, and ulceration, states which, 
if once established, leave no ground for hope. These processes, how- 
ever, are all peculiar: the softening is not that of phlegmonous abscess; 



OF THE CERVIX AND OS UTERI. 287 

for, while one or several parts of the indurated mass may entirely lose 
their hardness, and become really pulpy, other portions in immediate 
proximity with these, may still retain their solid and stony feel. The 
pus, too, in cancerous suppuration, will often be ichorous, thin, and 
variously coloured, often peculiarly and extremely offensive, and exco- 
riating the parts with which it comes into contact ; while the ulceration 
is frequently very painful, and not only contaminates and destroys sur- 
rounding parts, but has, springing from its surface, fungoid growths, 
soft, easily lacerable, and bleeding on the slightest touch. In other 
instances, where the muciparous glands, so numerously existing in the 
channel of the cervix, and around the margin of the os uteri, have be- 
come scirrhously indurated and granulated; and where remedies have 
failed, or have been either too late or carelessly employed, I have 
watched the same process of degeneration and gradual ulceration, till 
at length the natural form of this appendage to the womb has been en- 
tirely destroyed, and instead of a small aperture, into which the tip of 
one finger only could with difficulty be passed, there has been formed, 
by this destructive and malignant process, an opening large enough to 
receive easily three or four fingers. 

Still, without careful and frequently-repeated examination, both by 
the touch and the speculum, it will be difficult accurately to appreciate 
the extent and the progress of these destructive changes. Not that, if 
they are about to occur, we shall be lon^ in doubt ; for there are other 
indications of a coming change, too distinct to be misunderstood ; but 
I am sure that, without such investigations, we shall frequently mistake 
a transient and accidental attack of indisposition and weakness for an 
irremediable aggravation of the disease. Any one who has watched 
the march of cancer of the womb, cannot fail to have been struck with 
its insidious advance ; first, a decline of strength, which has from day 
to day been scarcely perceptible, becomes at length painfully evident, 
when an exertion is attempted, which perhaps only a month before was 
easily borne. Then the appetite begins to fail, and must be tempted 
with highly-flavoured food ; the bowels having been previously slug- 
gish, are now occasionally purged, and without any powerful aperient; 
and a day or two may elapse before the exhaustion induced by such a 
diarrhoea is recovered from. In a little time the constipation returns, 
and injections are necessary to procure relief, scarcely ever obtained 
without some suffering, and often not without severe pain. However 
we may desire to conceal the fact, soon emaciation begins, and the yel- 
low whiteness or pale leaden hue of the skin, and the tapering of the fin- 
gers, and the general diminution and putty-like softness of the solids, 
the oedema of the extremities, the daily fever, the general derangement 
of the functions constituting the cancerous cachexia,— painfully attest the 
progress of the disease. There is often, too, at this period, a distressing 
restlessness, preventing sleep, irritation of the neck of the bladder, 
prompting to frequent and unsatisfactory efforts to pass water. Fur- 
ther inquiry seldom fails in bringing to light the fact of an increased 
amount of purulent and ichorous discharge ; and it is not long before 
hemorrhages, sometimes very profuse, and coming on without any 
undue exertion to account for their occurrence, confirm the conclusion, 



288 ORGANIC DISEASES 

that the disease is certainly progressing. If there has been no severe 
or constant pain before, it often begins now ; and if the malady has 
been throughout painful, it generally happens, when the ulceration is 
thus more rapidly contaminating and destroying surrounding parts, 
that opiates must be given, at least once, and often twice during the 
day. In many instances, patients are at a loss to express in terms suf- 
ficiently strong, the agonizing and constant suffering induced by the 
burning and lancinating pain about the neck of the womb and neigh- 
bouring parts. 

If an examination by the speculum be made at such a juncture, it 
will generally reveal either decided and spreading ulceration, or a 
prominent and florid elevation of the lining of the channel of the cer- 
vix, exposed to view either by a wide and capacious, or by a partially 
destroyed os. It too frequently happens, that an investigation has not 
been made till this period ; and it is indeed most disappointing to be 
compelled to believe, and cautiously to tell the friends of the sufferer, 
that the disease is entirely hopeless. It would be as wrong, even in 
such a state, at once to announce its real character, as it would be to 
abandon the patient to insufficient and partial efforts of palliation. There 
is yet much to be done ; and as it is impossible to say how long life 
may be protracted, so we ought, by every possible means, to smooth 
the approach to death. Lately, in a case where the hemorrhages, 
although small, were frequent, and where the os was fissured and 
granulated, ulceration being erroneously supposed to exist, an abandon- 
ment of all active treatment was recommended. And yet in this in- 
stance, the application of a very strong solution of lunar caustic, daily 
injections of a saturated alum lotion, a regulated diet, and a sparing 
exhibition of narcotics, have kept the disease stationary for three years 
— four months having been predicted as the utmost extent to which life 
could possibly be protracted. Such opinions should not be hastily 
given. There is neither empiricism nor fraud in an opposite course. 
It is certainly wrong to promise a cure ; but if life can be prolonged 
for months without painful treatment, and with some considerable mea- 
sure of comfort, it is right to afford the patient such a chance of an arrest 
of the malady. 

It would be scarcely proper in a history of advanced cancer, if I were 
not to mention, that it is not uncommon, before the final issue, for the 
, whole cervix to be destroyed, the aperture of the womb, thus formed, 
being filled up by a tolerably firm and immovable, or a softer fungoid 
mass ; nor is it rare for the vagina, rectum, urethra, and bladder to be 
involved in this general ulceration. The attendant sufferings in many 
instances, may be conceived, but they can scarcely be described. It 
were easy to amplify this narration, but enough, probably, has been 
practically stated, to show the pathological importance of cancer of the 
womb, its general incurability, especially if it be neglected in its early 
stage ; the agonizing pains so often attendant on its protracted course ; 
its extraordinary power of growth and dissemination ; and its loath- 
some destruction of surrounding parts. 

The treatment of the advanced disease, although essentially pallia- 
tive, must of necessity be complicated ; and that practitioner treats it 



OF THE CERVIX AND OS UTERI. 289 

best, who, by assiduous watchfulness and skilful adaptation of our many 
resources, checks almost all, and removes many of its painful incon- 
veniences. At the end of the chapter will be found some remarks on 
the removal of the entire uterus, an operation now abandoned, and on 
the excision of its cervix. 

There is generally somewhat of a consecutive order in the after- 
symptoms ; and although each case may, in its course, present marked 
variations, still there are indications of gradual aggravation, too simi- 
lar, to be either mistaken or overlooked. 

The discharges, the hemorrhages, the advancing ulceration, the pain, 
and the various constitutional affections of cancer, in turn, and often ex- 
isting together, call into exercise every palliative measure. In some 
instances, however ably and perseveringly employed, all our efforts 
fail : the pain is so intense, burning, and constant, and the effects of 
opium, largely and constantly administered, so distressing, that we 
almost despair even of soothing such dreadful sufferings. These, how- 
ever, are but the exceptional and very rare examples ; and while truth 
requires such a statement, it is a happiness to be able, with as much 
truth to declare, that in by far the greater number of instances such 
aggravations do not exist. 

The Discharges.— It has been said, that after the commencement of 
ulceration, the discharge always, and at once loses the character of 
the usual vaginal secretion, and is not only augmented in quantity, but 
becomes so fetid, as exceedingly to distress both the patient and her 
attendants. Such a result is by no means invariable. The discharges, 
even in the advanced stages of the malady, vary much. Sometimes, 
and for many weeks together, they are free from acrimony and odour ; 
and so small in quantity, and so rarely even tinged with blood, not to 
mention the long absence of hemorrhages, that, but for painful experi- 
ence to the contrary, a sanguine hope of cure might be entertained. 
I acknowledge that such appearances do not last. At the moment, 
perhaps, when the hope thus excited is beginning to be confirmed, the 
discharge again becomes profuse, tinged with blood and ichorous, or 
it may suddenly and entirely cease, being superseded by an unexpected 
copious uterine bleeding. The practitioner must not then be misled 
by these appearances, and induced to give a too favourable opinion. 
I have known the discharges to be scarcely fetid till within a few 
weeks of death ; and several times I have been astonished, where fcetor 
has been absent, to discover the cervix extensively ravaged by ulcera- 
tion. There can be no doubt that the emaciation is partly attributable 
to these constant drainings ; and the advance of the malady, however 
insidious it may be, is almost always proportionate to their amount. 
Still, although every kind of discharge may, in some instances, be en- 
tirely absent, one cannot fail to be struck with the fact, that, where ul- 
ceration has really commenced, there is never, even for a day, a complete 
freedom from some of the symptoms marking the existence of a ma- 
lignant and irresistible disease. Thus, if an alarming bleeding has 
been arrested, the discharge, be it purulent, muco-purulent, sanguine- 
ous, or watery, will immediately return ; and where there has been no 
bleeding or a diminished discharge for several or many weeks, the 



290 ORGANIC DISEASES 

pain and restlessness, the fever and peevishness, are usually distress- 
ingly aggravated. Thus, the anodyne has to be increased, and after 
a little further time, although there may have been a long apparent 
arrest of nearly all the worst symptoms, the disease has been work- 
ing, and increasing emaciation and declining strength cannot be con- 
cealed. 

Even after many such vicissitudes as these, a temporary lull of the 
symptoms induces a new and fondly-cherished hope, to be indulged for a 
time and again to be destroyed, till at length it becomes too evident, 
that impending death cannot much longer be warded off by human 
means. 

It is unnecessary to repeat what has been already enjoined (page 
276) as to the constitutional management ; but a few practical hints as 
to the local treatment of the discharges, may not be without advantage. 

It may be remarked most truly, that the practice of employing sti- 
mulating and astringent injections, whenever there is vaginal discharge, 
is far too general, and, in cancerous diseases, often decidedly injurious. 
So long as the loss is not excessive, acrid, or odorous, tepid or cold 
water may be injected into the vagina once or twice a-day. The 
comfort of the patient is for a long period secured by this simple pro- 
cedure ; and often have I heard the most distressing complaints, when 
the advance of the fungoid ulceration, and the impossibility of touching 
it without producing bleeding, have precluded its further adoption. 

When the discharges are more excessive, or not having been so be- 
fore, become offensive, there is always an anxiety to use injections. 
They are not, however, invariably beneficial ; for there are many 
cases where pain and increased loss are the consequence of their use. 
In such, a return to emollient and slightly narcotic lavements often 
produces the best effects. There are few points in the treatment of 
advanced cancer requiring more caution than injections. The mus- 
tard injection (Form 45) may be used occasionally, once daily, or 
two or three times weekly, when the parts are extremely relaxed, and 
when the discharge is thin and ichorous. Reduced to such a strength 
as shall only produce a moderate sensation of heat and tingling, I 
have often known, of course in the very earliest beginning of ulceration, 
this stimulant remedy arrest and improve the character of the dis- 
charge, and allay pain. One patient employed it for many months 
most beneficially, and she never ceased to regret its disuse. Formu- 
lae 34, 36, 37, and 38, are highly sedative, the temperature at which 
they are used being made to suit the feelings of the patient, and the 
risk there may be of bleeding. As astringents, Formulas 55, 56, 
and 58 are valuable, particularly in the earlier periods of the con- 
firmed malady. It must never be forgotten, however, that when in- 
jections fail in diminishing the amount and fcetor of the discharges, 
and certainly when prolonged local pain succeeds their administration, 
they must then be laid aside. I have often witnessed the good ef- 
fects of injections of nitrate of silver, gr. x.,xv.,or xx. to the ounce of 
distilled water. They generally soothe pain, and it is not at all un- 
common, after their prolonged employment, to find both the acrimony, 
and odour, and quantity of the discharge greatly diminished. The 



OF THE CERVIX AND OS UTERI. 291 

same observations are partially true of the sulphate of iron; Jj. vel 
3iss. to the pint of distilled water, two or three ounces being used two 
or three times a-day. For a time the happiest results have followed 
its use ; and several patients have thought it was certainly curing the 
disease. It need scarcely be said, that such expectations have been 
disappointed. As the disease advances, the injections are gradually 
laid aside, the pain and bleeding following their employment justifying 
their discontinuance. Tepid water alone, or with a little eau de Co- 
logne, gin, or brandy, must, as ablutions, be still resorted to ; and the 
comfort of the sufferer will be long maintained by the judicious use of 
chlorate of lime, and frequent clean linen. 

In concluding this chapter 1 may observe that there is frequent and 
almost sudden change in the odour, colour, and consistence of can- 
cerous discharges. For several weeks they may be almost insuppor- 
tably fetid and thin, after which the ulceration being temporarily 
stayed, their offensive smell may cease. Their colour is various: a 
yellow, aud rather dirty-white discharge, copious, thin, and more or 
less acrid, with lymph, or membranous coagula, is most common: but* 
the diet and the treatment, as well as the stage of the malady, mate- 
rially influence these conditions. The discharge may be dark-brown, 
or even black, and of course its consistence as well as its colour will 
vary with the amount of blood, and the products of ulceration partially 
dissolved in it. Excoriations about the labia and orifice of the vagina, 
extending to the anus, and the upper and inner part of the thighs, 
vastly augment the patient's sufferings. It is an old and true remark, 
that a practitioner conversant with this awful disease, will generally 
diagnose it correctly by the peculiar odour of the discharge. 

The Hemorrhages. — These are almost sure to occur in every case. 
Sometimes bleeding, and to a considerable extent, is the first symptom 
which excites alarm ; and often, in the early stage of ulceration, the 
hemorrhages are larger and more frequent than that at a more ad- 
vanced period. There is, however, the utmost uncertainty as to their 
occurrence, continuance, and repetition. Sometimes I have thought, in 
cases where I had examined frequently, that I could predict the time 
of the bleeding, from the heat, tenderness, and congestion of the cer- 
vix and adjacent parts ; but, although occasionally correct, I have often 
been wrong. It is probable, that the progress of ulceration is some- 
what checked by the hemorrhage, if we except the bleedings of the 
very advanced disease, and certainly the pain is for a time relieved. 
It is extraordinary that women should rally after some of these losses. 
I have known several pints come away by gushes, and twenty or 
thirty napkins to be entirely saturated. Such bleedings require the 
same treatment as uterine hemorrhage ; and brandy in considerable 
quantity, lead, and opium, are indicated. Plugging with soft tow may 
be required, and ice has been placed in the vagina in bladders round 
the abdomen and loins. Happily these excessive hemorrhages have 
usually a long interval, and both the practitioner and patient are most 
careful to prevent their repetition. I have at present under my care 
a lady, who has three or four times almost miraculously emerged 
from these immense losses, the syncope and death-like collapse having 



292 ORGANIC DISEASES 

lasted many hours. The injection of cold or iced water into the rec- 
tum, has in some instances suddenly checked them. But often our 
means are of little avail in the restraint of the actual loss, the blood 
coming away in such sudden and large gushes, and then as suddenly 
stopping. Our efforts in such cases must be sedulously directed to 
sustain life. If the pain is thus relieved for a time, and the ulceration 
partially delayed, it cannot be doubted that the weakness, and the im- 
paired appetite and digestion, and the febrile reaction and want of 
sleep, and many other evils following in the train of these hemorrhages, 
more than counterbalance any benefit. The ergot is scarcely ad- 
missible here; generally it has seemed, in my hands at least, to act 
as a local stimulant, and to keep up and increase the hemorrhagic ten- 
dency. 

It must not be forgotten, that death may ensue immediately from 
these excessive bleedings, and perhaps one of the least painful termina- 
tions of life, under such circumstances, is its gentle and gradual ex- 
tinction in prolonged syncope and collapse. 

The advancing Ulceration. — I have already alluded to the destruction 
of surrounding parts, although I have scarcely mentioned the indica- 
tions by which, independently of the finger and speculum, such pro- 
gress may be predicted. Examinations after the disease has com- 
menced its full ravages, are not only useless but injurious. They give 
pain, shock the delicacy of the patient, and frequently cause bleeding. 
It may be inferred, when the bladder begins to sympathize, when there 
is an almost constant deposition of mucus from the urine, and dysuria, 
that there is at least thickening of the urethra and swelling of its ori- 
fice. Occasionally in this state it is necessary to use the catheter, 
which can scarcely be done without pain ; and when the ulceration 
has reached the bladder, and the fungoid mass presses upon its neck, 
and pushes the urethra out of its course, it is a matter of great diffi- 
culty to draw off the urine. Montgomery remarks, that for some 
days before the bladder gives way, there is retention of urine, and di- 
latation of the ureters, which are found, after death, thin, distended, 
and diaphanous. Many patients suffer from diminished calibre of the 
urinary canal, and certainly this outlet and the bladder are more fre- 
quently and painfully implicated in cancer uteri than the rectum ; 
doubtless owing to their closer approximation, and to the very little 
cellular tissue placed between them. Life maybe miserably prolonged 
for some time after the perforation of the bladder and rectum ; but it 
need scarcely be remarked, that the involuntary escape of the urine 
and the faeces, but especially the almost constant dribbling away of 
the former, must, by inducing excoriation and sloughing, awfully ag- 
gravate the suffering. 

That the walls of the uterus are about to give way, may sometimes 
be inferred from increased difficulty and pain in relieving the bowels, 
arising from the pressure of the abdominal contents upon the diseased 
cervix and rectum. 

In advanced cancer of the womb, a vaginal examination will always 
detect some of the following deviations from healthy structure : — 

The cervix may be ulcerated throughout ; it may be entirely de- 



OF THE CERVIX AND OS UTERI. 293 

stroyed ; or the ulceration may be confined to the anterior or posterior 
half. 

The diseased surface is usually rough and uneven, seldom very ten- 
der on pressure, and the finger, when withdrawn, is usually covered 
with a discharge more or less fetid and tinged with blood. 

In many instances there is a fungoid mass, soft, and lacerable, but 
occasionally harder, and almost immovable, springing from and filling 
up the lacerated aperture of the os, to be in its turn the seat of fresh 
ulceration. 

The vagina and rectum are not unfrequently partially destroyed, 
but it is not common for cancer of the cervix to carry its ravages far 
down either of these canals, death generally occurring before such an 
extension. The colour and consistence of the ulcerated masses vary 
considerably. Sometimes I have seen them nearly black; at other times 
dark-gray or approaching to a flesh colour. It is not rare for them to 
be very firm, or so lacerable, as scarcely to bear examination without 
rupture and hemorrhage. 

Where a fistulous opening into the bladder has long existed, some 
chemical action often occurs between the urine and the secretion from 
the ulcer; and in a case lately under my care, the surfaces of the ul- 
cerated masses were so thickly coated with gritty and earthy material, 
as to impart quite a hard, resisting feel to the finger. In the hospital, 
the same thing has several times been observed. Many remedies have 
at various times been tried to arrest the progress of confirmed cancer- 
ous ulceration. In none have I any confidence. The utmost we can 
hope for is alleviation of pain, and this is often beyond our power. 
Opium in every form, conium, the tincture of benzoin, and the nitrate 
of silver, alone and in combination, have sometimes relieved, but more 
generally they have failed. Mustard, and poppy, and alum baths, hot 
tepid, and cold, have occasionally alleviated the agonizing pain, but 
have failed in checking the ulceration. Certainly those cases seem to 
do the best where there is the least local meddling, beyond a scrupu- 
lous attention to cleanliness. 

The pain. — The popular opinion, that cancer of the womb is invari- 
ably accompanied by acute suffering, is certainly incorrect. But it is 
true that in some instances, scarcely any infliction can equal, and cer- 
tainly none can exceed its agonizing, burning, and lancinating pain. 
Often is the inquiry urged by anxious relations, whether the case is 
likely to be one of extreme suffering? We cannot always give a sa- 
tisfactory reply; for there are examples where irritation and local un- 
easiness are coeval with the malignant deposit. The various painful 
symptoms, in such cases, soon show themselves, and it is not wrong 
to prognosticate most unfavourably. In these we are not long in 
doubt; remedies have but little power, and our only hope is, that the 
extreme severity of the disease will be compensated by the shortness 
of its course. In other instances, the scirrhous stage lasts long, and 
ulceration goes forward with but slight indications of its existence; 
while in a third class, by no means a small one, either in private or 
hospital practice, there is no pelvic pain at all. By most, the pain is 
described to be lancinating, as though sharp knives were constantly 



294 ORGANIC DISEASES 

being plunged into the neck of the womb ; and so constant is this cha- 
racteristic, that some authors found on it the diagnosis between corro- 
ding ulcer and cancer. There are, however, not a few cases in which 
the hot, the burning character, constitutes its great aggravation. In 
the milder forms, where the progress is very slow, the pain is wearing 
and constant, but endurable. There is sometimes a peculiar pain about 
the rectum and anus, attended by a sensation of bearing down and 
prostration, increased by the erect posture, and often by the warmth 
of the bed. Nor is it very uncommon that the principal suffering is 
away from the uterus, in the loins, iliac fossae, or along the course of 
the sciatic nerve; not perhaps constantly present, but recurring by pa- 
roxysms, and lasting during the whole night, or through several hours 
of the day. 

It cannot, after what has been said, be matter of surprise, that patients 
occasionally sink rapidly, as the c'onsequence of these agonizing pains. 
One such case, and I could mention several, I have narrated at page 
274; and MM. Bayle and Cayol remark, that "these pains are some- 
times so acute, that persons have been known to die of convulsions or 
delirium, occasioned by cerebral fever." 

In the 5th volume of the Dublin Hospital Reports, Dr. Montgomery 
adduces a similar example. 

It is unnecessary to dwell long on the best methods of alleviation. 
My experience has taught me, that opium alone can be relied on. At 
first, hyoscyamus, conium, poppy, and hop may avail; but generally, 
so soon as the pain becomes intense, agonizing, andjiearly continual, 
these milder anodynes will be laid aside. For a time, the various pre- 
parations of morphia may be tried; but it will be found, especially 
when frequently and largely administered, that they do not procure 
either decided remission of the pain or real sleep. Distressing visions, 
hysteria, and prolonged and useless narcotic effects, even when awake, 
often disincline the patient to their continuance. I have not yet dis- 
covered any anodyne of equal excellence with the tincture of opium. 
I do not mean to affirm that there is no mischief arising from its daily 
employment: full well do I know the contrary. But we have only a 
choice of evils, and no one can hesitate between the inconveniences of 
the anodyne and the pains of cancer. For many months opium will 
procure sound sleep through the night, and enable the patient cheerfully 
to endure the miseries of the day. It is, however, desirable, if it can 
be done, occasionally to suspend its use, especially when, by its exhi- 
bition for many weeks, it has impaired the appetite, and so offended 
the stomach, as that there is very frequent retching and sickness. 
The distressing results of opium are various: headache and vomiting, 
constipation and fever, diminished secretion of urine, great weakness, 
both of mind and body, may all be enumerated: but retching and vomi- 
ting are the indications most frequently demanding its temporary disuse. 
It is right to begin with not more than ten or fifteen drops, and to in- 
crease it as slowly as possible. Its taste may be disguised, and its 
efficacy increased, by the addition of a teaspoonful of Spir. Lavand. C. 
and brandy. The latter ingredients require to be increased in propor- 
tion to the laudanum; thus, for a patient on whom I am now in daily 



OF THE CERVIX AND OS UTERI. 295 

attendance, the nightly draught contains nearly two hundred minims 
of the tincture, and a tablespoonful each of brandy and the compound 
lavender spirit. Montgomery has truly remarked of the very painful 
instances of cancer of the womb, that " temporary relief can be found 
only in opium, and permanent rest only in the grave." 

Of the various Constitutional Affections. — There is perhaps no such 
example of universal depravation of system. Every organ suffers, and 
the anaemia and emaciation in some instances cannot fail to astonish. 
A brief enumeration of the various derangements is all I shall attempt. 

The pulse is generally quick, sometimes full and hard, but after fre- 
quent hemorrhages, it becomes soft, compressible and wiry. There 
is daily fever and frequent perspiration, and but for the opiate, and 
often in spite of it, want of rest. The skin changes remarkably ; it is 
hot and dry during the day, and quickly becomes shrivelled, and as- 
sumes a dirty, putty-like or leaden hue. There is in all cases more 
or less wasting, and when the disease is advancing rapidly, the in- 
creasing emaciation is daily more evident, till at length the bones are 
nearly denuded of flesh, and the greatest care is required to prevent 
excoriation and slough. However reduced a patient may be by can- 
cer, there will be a marked difference between the distress and irri- 
tability attending it, and the dying languor of phthisis. There is often 
intense thirst and heat in and about the stomach. Sometimes, but 
very rarely, the constipation is distressing ; and Montgomery has re- 
lated a case, where the passage* of the faeces was fatally arrested by 
pressure on the rectum, from an enlarged condition of the pelvic glands. 
Diarrhoea is common, and from the difficulty of checking it, is often 
very alarming. 

The state of the abdomen varies : sometimes it is tense and distended, 
and at others sunk and relaxed. I have once seen a general anasarca. 
Of coincident deposition of cancerous matter in other viscera, I cannot 
say much from personal observation. The liver and lungs are be- 
lieved to be most frequently affected. Several times, in the examinations 
at Guy's, I have known the opinion verified in reference to the lungs, and 
I have once in the same Institution seen a coincident deposition in the 
mammae and uterus. 

It is not a matter of surprise, in such cases as these, where medi- 
cine professes only to palliate, and where even palliation is often be- 
yond its power, that the bolder and more desperate expedients of the 
partial or entire extirpation of the diseased organ should have been 
resorted to. 

Excision of the neck of the uterus has long been practised on the conti- 
nent, and several times in this country. Professor Simpson of Edin- 
burgh has lately published an extremely interesting case. The patient 
not only quickly recovered, but Dr. Lewins of Leith, who attended 
her in the subsequent confinement, remarks, " that it is certain that 
conception took place within ten days from the date of the operation." 
In his paper published in March, 1841, in the Edinburgh Medical and 
Surgical Journal, two instances are quoted from Dr. Ingleby. In the 
first of these, the operation was performed for cauliflower growth. 
; 'The disease was unaccompanied by pain ; but there was hemorrhage, 



296 ORGANIC DISEASES 

serous discharge, dropsy of the extremities and face, with general 
anaemia. All the disease was removed which was connected with 
the uterus. Small bits, however, grew from the mucous membrane 
of the vagina. Whether caustic would have succeeded in eradicating 
these, I am unable to determine, as thoracic inflammation came on a 
few days after the operation, and the patient died from it and the effects 
of a very large vomica in one lung. Every part of the body was 
sound except the lungs and the mucous membrane of the vagina, just 
below the cut surface of the cervix uteri, and opposite the os and vagi- 
nal portion of the organ." 

Dr. Ingleby once also excised the cervix for a malignant fungus, 
which did not extend above the os uteri more than a quarter of an 
inch. The patient, who was almost moribund prior to the operation, 
became apparently quite well, actually got fat, and remained in good 
health for a year. The disease then returned in the vagina and blad- 
der, in consequence of which she died. 

A third case is cursorily related by the same physician, in which 
he witnessed the performance of the operation. The progress of the 
malady was not, however, arrested by it. 

Lately, I had under my care at Guy's a patient whose cervix has 
since been amputated by Mr. Lawrence, in St. Bartholomew's Hos- 
pital. I thought, after careful examination, that the induration had 
extended to the body of the uterus, and in consequence I declined its 
excision. The removal was effected by drawing down the neck, and 
severing it from the body of the womb by a bistoury. Dr. Rigby in- 
forms me, that there was serious hemorrhage, but the recovery had 
been quick, and thus far satisfactory. 

Osiander, Professor of Midwifery at Gottingen, published a minute 
account of his method of removal, in nine successful cases ; and to him 
belongs the distinction of having first, in 1801, practised this impor- 
tant operation. 

Dupuytren, Recamier, and Lisfranc, have sanctioned and performed 
it. The latter surgeon asserts, that ninety-nine cases have fallen under 
his care ; and if his statements and opinions could be relied on, no ap- 
prehension either of hemorrhage or of a return of the disease, need be 
entertained. But M. Pauly, his assistant, affirms, 1st, That Lisfranc's 
cases amount only to fifty-three (still a goodly number). 2. That there 
are no exact accounts of the failures which happened in hospital. 3. 
Out of nineteen private patients operated upon, one only had been per- 
manently benefited. 4. Of these nineteen cases, four died within 
twenty-four hours, twelve had an immediate relapse, and in two others, 
the carcinoma not being entirely removed, the patient only sank the 
more rapidly. 5. Out of nine patients operated on under M. Pauly's 
observation, and near whom he remained twenty-four hours, six were 
attacked with frightful hemorrhages ; and of these six, three died 
within twenty-four hours. In addition, abundant proof is afforded, 
that in many cases excision was really uncalled for by the nature of the 
disease. 

Dr. Churchill appends to these statistics the following observa- 
tions : — " Such facts are enough to deter the most hardy from at- 



OF THE CERVIX AND OS UTERI. 297 

tempting this fearful operation ; and the exposure of such misstate- 
ments is a striking lesson to all who, in order to make a reputation, 
are ready to forsake the paths of honour and truth." 

M. Dupuytren had fifteen or twenty successful cases ; M. Hervez de 
Chegoin, one. 

MM. Blandin and Velpeau have both lost patients after it, and the 
latter observes: — "Without entering into the question, whether ex- 
cision of the cervix uteri may not have been frequently performed in 
cases in which there was no cancer, I will merely observe, that M. 
Dupuytren, who has, as it were, naturalized the operation in France, 
seldom has recourse to it at the present moment ; that M. Lisfranc, 
who has so often succeeded in it, appears to adopt it less frequently 
than heretofore ; and that, according to M. Heisse, Osiander discon- 
tinued it some time before his death." 

Method of operating. — There are two modes of excision. — The first : 
Having introduced the speculum to obtain a clear view of the part, 
fix the forceps of Museux, or any other having hooks at their extremi- 
ties, into the cervix, and gradually draw it down till it passes a little 
beyond the os externum. In this way the line of junction of the va- 
gina with the neck of the uterus is seen, and this line must be the limit 
of the operation. Then, by a blunt-pointed bistoury placed at the 
posterior part of the cervix, and at the proper height, excise as com- 
pletely as possible the diseased portion, the direction of the knife be- 
ing from below upwards. The position is the same as for lithotomy, 
and the operation is by no means a painful one, the principal suffer- 
ing arising from the depression of the womb. — In the second method, 
the excision is completed within the vagina, and without depressing 
the uterus. Many instruments have been devised for this operation, 
the intention of which is the avoidance of the distressing and painful 
depression of the womb. Several of these are ingenious, but from 
their complication, useless. Some are painful and difficult of intro- 
duction, and even if successfully used, complete the removal less 
easily and effectually than may be done by the hooked forceps and 
bistoury. 

There can be little difficulty in appreciating the merits of these two 
methods ; for that plan must be the best, which allows the whole ex- 
tent of the diseased structure to be seen, without which it can scarcely 
be effectually removed ; nor do I believe, where the hooked forceps 
are carefully introduced, and the cervix gradually drawn down, that 
there will be much suffering ; certainly not so much as will of neces- 
sity be inflicted by the bruising, and tearing, and repeated incising and 
scooping, consequent on the use of the occult and elaborate cylinders, 
scissors, and knives. 

The extent of the disease, compatible with the hope of a cure, and 
its unavoidable dangers, are to be maturely weighed in each case. 

1. Whenever the indurated or malignant deposit, or ulceration, 
extends beyond the neck into the body of the womb, the operation is 
indefensible. 

2. Where the disease of the cervix is thus limited, if the pelvic 
glands or adjoining cellular membrane are enlarged by deposition, or 



298 ORGANIC DISEASES 

have been long indurated, the whole of the disease cannot be removed, 
and therefore any attempt at excision would be blamable. 

3. The immobility of the uterus is an insurmountable objection. 

4. Vascular congestion of the womb and ovaries is at least a rea- 
son for delay. Excision, in such a condition, will probably be at- 
tended and followed by dangerous hemorrhage. 

5. Serious affection of the general health, confirmed " cancerous 
cachexia," phthisis, or organic disease of important viscera, are posi- 
tive prohibitions. 

We cannot wonder, with so many limitations, that Montgomery, 
Blundell, Robert Lee, and many other eminent men, should condemn 
the operation as of scarcely any use ; and yet I cannot but think, now 
that uterine diseases are so much better understood, and the absolute 
necessity for early examination by the speculum as well as the finger, 
so universally conceded, that opportunities w T ill more frequently pre- 
sent themselves for its justifiable and successful performance. I have 
often been surprised that so very few, scarcely any, cases occur at 
Guy's, in which removal would be at all allowable. Frequently for 
months, and I may say years, I have anxiously examined with a view 
to excision, and have been disappointed by finding the disease too far 
advanced. Hence I have been induced to believe, that in many of 
Lisfranc's cases, the operation was performed for chronic congestion, 
not cancer of the cervix. But we may not yet have arrived at a dis- 
passionate and just estimate of its value ; and it is more than probable 
that hitherto, excision has generally been practised, either in affections 
not malignant, or at a too advanced period of real cancer. 

The following conclusions are perhaps correct : — 

1. That the operation is an easy one. 

2. That excessive and dangerous bleeding is not a necessary ac- 
companiment. 

3. That in some instances, for the time over which subsequent ob- 
servation has extended, cancerous ulceration of the cervix uteri has 
been cured by it. 

The dangers are, hemorrhage, either during or soon after the opera- 
tion (M. Pauly says, fatal bleeding is not common after the lapse of 
forty-eight hours) ; uterine or peritoneal inflammation ; malignant ulcera- 
tion of the excised surface, or of any portion of the diseased structure 
which may have been left behind. 

The plug or dry tow, and the application of cold, as heretofore re- 
commended, will probably arrest the bleeding, and where they entirely 
fail, the cautery may be resorted to. Bleeding, and the antiphlogistic 
plan, with calomel and opium, are the proper remedies for inflamma- 
tion, and a fresh excision, or some of the various caustics, for renewed 
ulceration. 

Extirpation of the entire uterus. — On the removal of the whole 
womb, in case of inversion and displacement, this is not the place for 
any remarks. But both on the continent and in this country, the can- 
cerous uterus has been extirpated from the pelvis by the knife. The 
former operation is easy, and comparatively safe ; the latter difficult 
of performance, highly dangerous, and almost uniformly fatal. 



OF THE CERVIX AND OS UTERI. 299 

Of Dr. BlundelPs four cases, three died shortly after the operation, 
and the fourth and most successful, within twelve or fifteen months. 
The preparation of the rectum and bladder in the last example, now 
in Guy's Museum, shows how ably and safely the operation was com- 
pleted, and how well the parts cicatrized ; but it also proves how diffi- 
cult, and nearly impossible it is, to form an accurate estimate of the 
extent of the malady and the risk of its return. Although the dis- 
eased viscus was wholly taken away, the rectum became the seat of 
malignant disease, and the patient died in the Hospital from invincible 
constipation. 

Velpeau has collected twenty-one instances of removal in twenty 
years, and there is not amongst them one instance of permanent cure. 
It seems unnecessary to observe, if circumstances, which I can scarcely 
believe, ever justify this frightful operation, that they must be nearly 
the same as those which limit the removal of the cervix. Especially 
ought the malady to be confined to the uterus ; the pelvic glands, the 
rectum, the bladder and the ovaries being free from its ravages ; and 
there should be such a condition of the general health as warrants so 
serious a surgical operation. Its great danger is the shock to the con- 
stitution. This may be judged of from the fact, that only one out of 
Dr. BlundelPs four patients rallied. The other three died before they 
had at all recovered from its effects ; and Madame Boivin remarks, 
that out of nineteen cases, most of them died on the second, or on the 
third day at the latest ; some in a few hours, or even a few moments, 
after the extirpation. 

I shall annex the history of Mrs. Moulden's case, and the account 
of the operation, as furnished to me by Dr. Blundell himself. 

" Mrs. M., aged 50, of gray eyes, tranquil disposition, broad in her 
make, and disposed to obesity, was seized with offensive discharge 
from the vagina, soon followed by eruptions of blood in large quantity, 
so that according to her own report, frequent faintings were produced, 
and the blood occasionally sank through a bed about twice as thick 
as a sofa cushion, collecting on the floor; and day after day, for 
months together, with little intermission, one or two pints of blood 
were discharged. 

' Although Mrs. M., in her general conversation, is by no means 
given to hyperbole, it seems evident that she must have greatly over- 
rated the quantity of these daily bleedings. Certain, however, it is, 
from her repeated and considerate declarations, that very large quan- 
tities of blood were lost during a period of many months ; and though, 
with the exception of some small cedema of the legs, there were no 
signs of general dropsy, the paleness, coldness, and weakness, and the 
frequent attacks of faintness or complete delirium, showed pretty 
clearly that much vascular inanition had been produced. In other 
particulars the patient's condition was not altogether discouraging; 
for the bowels were regular and the appetite was occasionally good ; 
and the appearance, though cachectic and perfectly similar to that of 
other women perishing under malignant ulceration of the uterus, was 
not such as to indicate a constitution wholly unfit for surgical ope- 
ration. 



300 ORGANIC DISEASES 

" The woman having been under the care of three or four different 
practitioners before I saw her, I deemed it proper to examine im- 
mediately with great attention ; when I found that the womb was 
movable, and about as large as a goose's-egg ; that its mouth was 
broad open, and of cartilaginous hardness; that it manifested the 
usual marks of malignant disorganization, in which also about one- 
fourth of the contiguous vagina was involved ; and, further, that on the 
surface of the diseased mass was formed an ulcer, about as broad as 
a shilling. The adjacent structures appeared to be healthy enough ; 
the bladder and rectum were sound, the inguinal glands were not 
enlarged, whence it was presumed that the lumbars were perhaps 
healthy ; the ovaries could not be felt to exceed their ordinary bulk, 
and there evidently was no tangible enlargement of the liver, spleen, 
kidneys, or omentum, all of which were examined with the nicest care. 
The breathing was easv ; the pulse, various in its frequency, ranged 
between 115 and 120 in the minute ; and the patient, though certainly 
very much debilitated, had sufficient remains of strength to walk to 
my house (the distance of a furlong), though not without considerable 
difficulty. ' To be short— it seemed clear at this time, that the case 
was ulcerated carcinoma of the uterus, as it is called, and that extir- 
pation was the only remaining remedy. 

" The bowels having been cleared, and the patient being resolved 
to submit to the operation, on the 19th February, 1828, I determined 
to remove the diseased parts without further delay. For this purpose, 
having placed the woman in the obstetric position usual in this country 
(on the left side, I mean), close upon the edge of the bed, with the loins 
posteriorly, the shoulders advanced, the knees and bosom mutually 
approximated, and the abdomen directed a little downwards towards 
the bed, I began the operation. 

" I commenced by passing the index and second finger of the left 
hand to the line of union between the indurated and healthy portions 
of the vagina, and then by taking the stem knife in my right hand, I 
could at pleasure lay the flat of the blade upon the point of these 
fingers, and urge the point of the instrument a little beyond the tip. 
The apex of the forefinger being in this manner converted into a cut- 
ting point, by little and little I gradually worked my way through the 
back of the vagina towards the front of the rectum, so as to enter the 
recto-vaginal portion of the peritoneal cavity, frequently withdrawing 
the stem scalpel so as to place the point within the tip of the finger ; 
and then making an examination with great nicety, to ascertain 
whether the vagina was completely perforated. 

"A small opening having been formed in this manner at the back 
part of the vagina, through this opening the first joint of the forefinger 
was passed, so as to enlarge it a little by dilatation and slight lacera- 
tion. This done, I proceeded to make an incision transversely, that 
is, from hip to hip ; for this purpose, carrying the finger with its cut- 
ting edge from the opening in the vagina already made, to the root of 
the broad ligament on the left side, so as to make one large aperture, 
I then took a second stem scalpel, having the incisory edge on the op- 
posite side of the blade, and laying this instrument on the forefinger 



OF THE CERVIX AND OS UTERI. 301 

as before, in such a manner, however, that the cutting edge lay forth 
on the other side of the finger, I carried the finger, thus armed, from the 
middle of the vagina, where the former incision commenced, to the root 
of the broad ligament on the right side, so that the diseased and healthy 
portions of the vagina behind became completely detached from each 
other. The back of the vagina, then, having been divided in this man- 
ner, I urged the whole of the left hand into the vaginal cavity, after- 
wards passing the first and second fingers through the transverse open- 
ing along the back of the uterus, this viscus lying, as usual, near the 
brim of the pelvis with its mouth backward, its fundus forward a little 
elevated just above the symphysis pubis. 

" This manoeuvre premised, taking a blunt hook, mounted on a stem 
eleven inches long, I passed it into the abdominal cavity through the 
transverse opening, and, with little pain to the patient, pushed it into 
the back of the womb near the fundus, and then drawing the womb 
downwards, and backwards towards the point of the os coccygis, as I 
carried the fingers upwards and forwards, I succeeded ultimately in 
placing the tips over the fundus in the manner of a blunt hook ; after 
which, by a movement of retroversion, the womb was very speedily 
brought downwards and backwards into the palm of the left hand, then 
lodging in the vagina, where at this part of the operation the diseased 
mass might be seen distinctly enough, lying just within the genital fis- 
sure. The process of removal being brought to this point, the diseased 
structure remained in connexion with the sides of the pelvis by means 
of the Fallopian tubes and broad ligaments, and with the bladder by 
means of the peritoneum, the front of the vagina and the interposed 
cellular web, parts which were easily divided, so as to liberate the mass 
to be removed. 

" The broad ligaments were cut through, close upon the sides of the 
uterus, and in dividing the vagina, great care was taken to keep clear 
of the neck of the bladder and the uterus. 

" The operation was facilitated by previous child-bearing, although, 
notwithstanding the discharges, there was little tendency to prolapsus 
uteri. Though the womb had bled so freely before the operation owing 
to the weakness of the circulation and other causes, yet not more than 
five ounces of blood were effused during its progress, the greater part 
coming away when the diseased structure was detached from the blad- 
der and vagina in front. The pain was not greater than that of an 
instrumental delivery, nor perhaps so great, nor did the patient require 
to be at all confined. The principal suffering was experienced when 
the vagina was divided behind, and when it was dilated by the intro- 
duction of the hand. There was no decided collapse when the perito- 
neum was first laid open, the intestines approached the aperture, but did 
not protrude; after the operation the sides of the vagina collapsed, 
and the aperture above seemed to be covered by a retroversion of the 
bladder. An indurated portion of the left side of the vagina, as large 
as the first joint of the little finger, was separately detached by the 
knife, after the completion of the rest of the operation. The pulse 
was distinct enough in the wrist during the greater part of the time ; 
but when the diseased portions had been completely removed, on the 
20 



302 ORGANIC DISEASES 

occurrence of the hemorrhage before mentioned, the beat of the radial 
artery was lost for about five minutes, the respiration being very fee- 
ble, and the patient lying, as after large floodings, very quiet. \\ hen 
brought to greater perfection, the method of operation will probably 
not occupy many minutes ; but in this instance, that it might be done 
more safely, it was performed very slowly, and like some deliveries 
by the forceps, it required more than an hour for its completion. It 
was not necessary in this case to vary the posture, the horizontal posi- 
tion being maintained throughout. The first incision was made at four 
o'clock, and the extirpation was finished by a quarter past five. lwo 
ounces of gin and water were given during the operation, and the 
same quantity after its termination, with sixty drops of the tincture 
of opium. Previously to the operation the pulse was 120, tongue 
clean and rather white, and her manner composed ; during its con- 
tinuance, and when at the height of agitation, it arose to 140 in the 
minute, when she became faint, and approached nearly to a state of 
asphyxia. Two hours subsequently to the operation, she was lying 
comfortably as if asleep, the whole body was warm, the pulse 92, and 
distinct, and the manner and countenance encouraging. On the third 
day there was great agitation and vomiting, and the pulse 112, with- 
out any obvious cause. Considerable solicitude was now entertained 
respecting her ; but happily, every uncomfortable symptom disappeared 
when the' bowels were freely relieved. For ten days there was a red- 
dish-brown discharge, and then for eight or nine days more it assumed 
a muco-purulent character, the flow from the vagina ceasing m a great 
measure on the nineteenth, and altogether on the twenty-first day. 
Shooting pain was more or less felt during the first three weeks after 
the removal of the uterus, on the left side, especially where the crural 
nerve is crossing the brim of the pelvis, under Poupart's ligament. It 
is now five months since the parts were extirpated, and the patient is 
fat and well, and designs to return to her husband. The interception 
of the access to the ovaries is a complete security against extra-uterine 
impregnation. The head of the vagina is closed by the bladder, 
which lies upon it. In future, it will, most probably, be necessary 
to vary the method of operating according to circumstances, nor is 
the operation here given proposed to the profession as the best. 
That its principal parts should be rendered visible is much to be 
desired, nor do I conceive this to-be impracticable. Let us remember 
what has been done for lithotomy, amputation, and the operation for 



aneurism." 



SIMPLE ULCERATION OF THE CERVIX AND OS UTERI. 

History and Symptoms.— I have already remarked, that there may 
be enlargement and hardness of the whole uterus, and especially of its 
cervix, without malignancy, such being the result of congestion and in- 
flammation. A similar observation is equally true of ulceration, which 
frequently arises from the same causes, and, throughout its course, even 
when protracted, never assumes the peculiar characters of cancer, 



OF THE CERVIX AND OS UTERI. 303 

cauliflower excrescence, or corroding ulcer. It is proper, therefore, 
that this simple ulceration be first understood, that we may be enabled 
accurately to distinguish it from the almost incurable maladies for 
which it may be mistaken. It is an extensive subject, requiring to be 
treated practically. 

There can be no doubt that ulceration of this portion of the uterus 
exists unnoticed, and that cicatrization takes place without remedies. 
Slight syphilitic sores, and the abrasions consequent on marriage and 
excessive intercourse, come within the scope of this statement. Nei- 
ther can it be doubted that ulceration arising from instrumental de- 
liveries and from abscess, the consequence of injuries, often escape 
medical attention. Women, in this country especially, prefer any 
amount of endurable suffering to an examination, which, even when 
allowed, is often uselessly made, if the finger, without the speculum, be 
alone employed. It is almost impossible otherwise to explain the suffer- 
ings through many weeks induced by coition ; the burning and painful 
sensations about the upper part of the vagina, and the sanguineous and 
purulent discharges so often complained of. These we cannot treat 
efficiently, because we are forbidden to investigate them properly, and 
yet they frequently recover. 

An examination by the speculum will reveal, even in these simpler 
and comparatively safe cases, ulcerations of varying extent and se- 
verity. 

1. Sometimes they are mere erosions of the mucous surface, redder 
than the sound membrane around, and the edges sharp and well de- 
fined. Such are not unfrequently seen after acrimonious leucorrhcea, 
the consequence of high living and excessive sexual indulgence. 

2. The ulcers of the cervix are occasionally numerous, varying in 
size from a small pea to a sixpence or shilling, the larger ones being 
evidently formed by a coalition of the smaller ; and long neglect may 
have induced roughness of surface and greater depth ; and the colour 
may be a darker red. In such sores there is commonly pain on pres- 
sure, and the speculum causes bleeding. The discharge, too, may be 
sanguineous and of a yellow or dirty- white colour; but usually, where 
there is no want of cleanliness, without fcetor. 

3. There is an ulceration following protracted local irritation, from 
pessaries, sponge, and contrivance to prevent conception, in which the 
cervix is enlarged and spongy, with increased heat and great tender- 
ness on pressure, and an open state of the os. In such cases, bleeding 
frequently occurs. 

Every remark now made may be verified in simple ulceration, at- 
tendant on entire procidence of the womb. We all know the varying 
extent and depth of such ulcers, and how extremely difficult they are 
to heal. I believe, that partial inflammation of the cervix, resulting in 
simple ulceration, is by no means uncommon ; an opinion which will 
be confirmed by the greater prevalence now than formerly, of exami- 
nations by the speculum. I am not aware that temperament has much, 
if any, influence ; but I have rarely if ever seen the cervix ulcerated 
prior to natural or vicious sexual intercourse. Prostitutes, as might 
be expected, are obnoxious to it. 



304 ORGANIC DISEASES 

The symptoms are somewhat equivocal, at least they are not ex- 
clusively attendant on a state about to terminate in ulceration. If, 
however, where the causes likely to produce it are known to have 
been in existence, there is almost constant pain in the loins, with sen- 
sations of heat and forcing about the anus, dragging and weight in the 
groins, abdominal pain and distention, occasional vaginal hemorrhage, 
shiverings, and a quick pulse, — an examination ought to be made. _ 

Causes. — There is no cause more frequent than cold. Insufficient 
clothing of the lower part of the person ; wet feet during menstruation ; 
the improper use of strong astringent injections, bougies or other fo- 
reign bodies; local injury, however inflicted, and many other circum- 
stances may be included. 

Diagnosis and Pathology.— It is desirable to be able to distinguish 
common from malignant ulceration of the cervix, and certainly the 
diagnosis is generally easy. The rapidity with which this simple ul- 
ceration occurs, plainly points to inflammation as its essential condi- 
tion. There is none of the induration produced by malignant de- 
posit : no immobility, no foetor and pain at all like what we observe in 

cancer. 

Its more stationary character and limited extent, the absence of 
large hemorrhages, the comparatively trivial constitutional effects, and 
the nearly inodorous discharge, sufficiently prove that it is not corro- 
ding ulcer ; nor, in most instances, will it be difficult to determine, 
whether there be a syphilitic taint about the affection. The moral 
character of the patient and of her husband ; the freedom from ure- 
thral discharge and inguinal swelling ; and the absence of the distin- 
guishing conditions of the cancer, will have their due weight. 

Treatment. — This will of course be determined by the stage and 
severity of the affection. If the patient has been so early examined 
as to induce the belief that although ulceration does not exist, it may 
yet occur, venesection may in some instances be advised. Local de- 
pletion, however, will be indispensable, and the blood may be abstracted 
by cupping from the loins or about the sacrum, or by leeches to the 
perinseum and vulva, the effect being increased by the hip-bath. In 
all such instances, excepting the cervix is exceedingly painful on pres- 
sure, or so enlarged, tense, red, and shining, as to lead to the convic- 
tion that an abscess is about to burst, leeches directly applied to it, or 
scarifications as heretofore recommended, are far more efficient. A 
few weeks since I saw a case where matter had formed, the cervix 
being enormously enlarged, hot, and indurated. I had previously 
wished to scarify, but after keeping the patient in the slipper-bath at 
100° for nearly an hour, I punctured the most projecting part, and 
more than a tablespoonful of pus escaped. There was rather exten- 
sive subsequent ulceration, but the healing was rapid and quite satis- 
factory. An injury from a pewter injecting syringe was the cause 
of suppuration. 

Whether local bleeding be practised or not, the recumbent posture, 

• hip-baths of salt water or medicated with poppy and conium, should 

be diligently used. Mild aperients, a spare diet, and sexual abstinence 

must be enjoined. Where the ulceration is slight, astringents, or three 



OF THE CERVIX AND OS UTERI. 305 

or four drachms of the oxide of zinc, in six ounces of distilled water, 
used as an injection three or four times daily, will often cure. Va- 
rious ointments may be recommended, and mercurial cerates have 
healed many ulcerations where there was no syphilitic taint. It will 
be inferred from what I have already said, in the chapter on Cancer, 
that I fully concur in the great utility of cauterizing these diseased 
surfaces. 

M. Lisfranc, generally so daring, seems inconsistently timid about 
the application of caustic. He regards " engorgement" of the uterus, 
and inflammation of the vagina or cervix, as events sufficiently im- 
portant to forbid its use ; the very affections which I have cured by 
cauterization, when other remedies had entirely failed. M. Lisfranc, 
with equal want of judgment, prohibits it where there is subsequent 
pain ; while with more reason he thinks that its application should be 
interdicted for four or five days before and after menstruation. The 
protonitrate of mercury has succeeded better in his hands than any other 
caustic. Jobert employs the pernitrate, and Delpech the acid nitrate of 
mercury. After a careful examination of remedies and their effects, I 
find none more efficient than the common lunar caustic, of varying strength 
and accurately applied ; the general health, and especially the condition 
of the bowels, require attention. 

Several times within my knowledge, the happiness of married life 
has been seriously interfered with by the pain " in coitu" consequent 
on slight or more severe ulceration of the cervix. Such instances are, 
for manifest reasons, long neglected ; nor is it till the evil becomes 
really almost intolerable, that an examination is permitted. Some- 
times the cervix is only abraded, its mucous surface being so irritable 
and tender, that every repetition of intercourse brings with it a repeti- 
tion of the abrasion, bleeding, and pain. Practitioners will, I know, 
recognise in this brief allusion, the facts of similar cases of their own' 
long neglected, because not thoroughly examined. Many of these I 
have healed by frequent and slight cauterization with the nitrate of 
silver, and in some of them, the cure has been attended by immediate 
restoration of sexual feeling, which had been long entirely absent. In 
a case of this kind, where the lady came from a foreign country to 
England for advice, the whole disease consisted of a pustular ulcer- 
ation, the invariable and immediate consequence of intercourse. The 
harmony of the parties had been destroyed, and the utmost incredulity 
was evinced when I stated, that there would be but little difficulty in 
the cure. The recumbent posture, the lunar caustic and oxide of zinc, 
with sarsaparilla and good diet, effected permanent improvement ; and 
when I last heard of the patient, then living in Hungary, she was per- 
fectly well, and about to be confined. 

Far more frequently than is generally supposed, painful intercourse, 
and eventually sterility and broken health, are dependent on acute and 
chronic inflammation and congestion of the cervix. Such cases from 
time to time fall under my care ; and although most of them are cura- 
ble by proper treatment, often have I to regret, that a delicacy of 
feeling which can hardly be too much commended, and a want of due 
appreciation of its importance by the attendant practitioner, have to- 



306 ORGANIC DISEASES 

gether prevented that examination, without which the cause of the ma- 
lady remains unknown, and the only effective treatment neglected. 
Not unfrequently do such evils continue for years, till disappointed hopes 
of cure induce a permission properly to investigate the disease. I trust 
that the suggestions now made will be sufficient, and that I shall, for 
manifest reasons, be excused for not dwelling at greater length on a 
class of cases avowedly not uncommon, and exceedingly important. 

CORRODING ULCER OF THE UTERUS. 

Definition. — An ulcer of granular surface, commencing at the cer- 
vix, rarely of large size, but destroying life by a corroding or eating 
away of the uterus, even to its fundus, and occasional^ implicating the 
bladder, vagina, and rectum. There is less pain than in cancer of the 
womb, from which it also differs, in there being no indurated deposit, 
no immobility, and no fungoid growths in the seat of the ulceration. It 
is malignant, and, except at its early commencement, incurable. 

History, Symptoms, and Pathology.— Dr. John Clarke of London has 
the merit of being the first who accurately described this peculiar and 
dangerous variety of uterine ulceration ; and I am not aware that sub- 
sequent writers have made any important additions either to its his- 
tory, pathology, or treatment. It is a rare disease. For one case of 
corroding ulcer we meet with ninety or a hundred of cancer of the 
uterus ; and I think there has not yet been received into the ward ap- 
propriated at Guy's to female sexual diseases, one example of Jhe ma- 
lady. On several occasions disease of the cervix uteri has been so 
mistaken ; but on examination, the ulceration was found to be carci- 
nomatous ; and out of five hundred recorded histories of female sex- 
ual maladies in that Institution, I do not find one of this affection. 

It is said especially to attack women of spare and lymphatic tem- 
perament, and rarely before forty years of age. In both these state- 
ments I concur ; although it has been met with much earlier. I have 
seen but two cases during twenty years. In both, menstruation was 
declining, and both were considerably alleviated by treatment. In 
one, life was prolonged for nearly five years after the first appearance 
of the nicer, there having been an interval of complete inaction of two 
years. In the second, the repeated application of caustic delayed the 
fatal event for a considerable time. Excessive bleeding terminated 
the life of one of the patients ; and the other gradually sank under the 
prostrating effects of the disease. In neither could an examination 
after death be obtained ; but in both, the ulceration had extended be- 
yond the cervix. 

The symptoms so closely resemble those of cancer, that the diag- 
nosis would be difficult, if the speculum were not used. Still, there 
seems to be something more hopeful about corroding ulcer. It ad- 
vances more slowly ; remedies have for a time more influence ; the 
discharge, the pain, and other inconveniences are generally less. 
Sometimes, however, in the interval of the hemorrhages, the dis- 
charge is peculiarly offensive ; and even in the absence of bleeding, 



OF THE CERVIX AND OS UTERI. 307 

I have known the patient distressingly annoyed for a few days, or 
even for several weeks, by its acrimony and fcetor. Pain and weak- 
ness in the back and loins are constant and distressing. Dr. Churchill, 
who has met with the disease more frequently than I have, says, that 
" in a few of the cases he has seen, no pain whatever was experienced 
from the commencement ; but the great weakness of the back was pre- 
sent in all." 

Towards the close of the malady, the patient becomes extremely 
emaciated, the discharge increases, daily and almost constant fever 
exists ; there is dyspepsia, diarrhoea for a few days, and then consti- 
pation ; and eventually she sinks, either from exhaustion, or from he- 
morrhage; or the disease may invade the cavity of the peritoneum, 
and give rise to fatal peritonitis. 

The pathology of the affection is not difficult to settle, if we are 
guided by its distinctive peculiarities. That it is the result of inflam- 
mation will be generally admitted ; and that the inflammation is of spe- 
cific character, appears equally undeniable. When examining it through 
the speculum, I have been struck with its close resemblance to lupus 
in external parts ; and the inflammation and ulceration preceding and 
accompanying it, assimilate it most closely with the same chronic and 
destructive process. Hereafter, when these concealed diseases come 
to be examined by the eye, as well as by the finger, their early changes 
and distinctive peculiarities will be better understood. We shall then 
discern more clearly the analogy between corroding ulcer and lupus. 

Diagnosis. — The finger and the speculum make the diagnosis easy. 
Already, in the definition, the main points of difference between can- 
cer and corroding ulcer have been pointed out. They consist in the 
absence of carcinomatous or other deposit, either before or during the 
progress of the malady, so that when the ulcer is examined through 
the speculum, its surface will be seen to be red, rough, and granular, 
with a distinct edge or line marking its extent. Adjacent to this, the 
uterine structure will be free from induration. Let the uterus so dis- 
eased be examined after death, and these statements will be strictly 
verified ; for, up to this line of demarcation, even where the disease 
has nearly reached the fundus, the neighbouring structures will be found 
perfectly healthy. 

The consequence is, that unlike what occurs in advanced cancer, 
where, owing to the new deposits and carcinomatous growths, the 
cavity of the pelvis is filled, and the uterus becomes fixed and im- 
movable ; in corroding ulcer, especially in its last stages, there is an 
empty space in the pelvis, and the remaining portion of the womb is 
especially movable. 

Prognosis. — Any promise of cure must be made with caution. It 
has been already remarked, that corroding ulcer is slower in its pro- 
gress and more amenable to remedies than cancer ; but the more fa- 
vourable opinion hence to be deduced, must still depend on the period 
when the ulcer is discovered. If it has not been detected till a great 
portion of the cervix has been destroyed, an unfavourable prognosis 
must of course be given ; and if, even at its commencement, the ulcer- 



308 ORGANIC DISEASES 

ation is but slightly controlled by cauterization, no expectation of cure 
can be held out. 

Treatment. — This is nearly the same as in cancer, only, that if early 
commenced, it may be anticipated that a less painful result will ensue. 
It has been remarked already, that corroding ulcer seems to be more 
a local malady than carcinoma ; and hence greater benefit may rea- 
sonably be expected from topical remedies. The lunar caustic pro- 
duces beneficial effects. It relieves pain and diminishes the quantity 
as well as the foetor of the discharge. If, notwithstanding this and other 
applications, the disease advances, palliation is to be attempted by opi- 
um, hyoscyamus, belladonna, and the various remedies mentioned when 
treating of cancer. 

It has been suggested, that excision of the cervix is the more appro- 
priate remedy ; seeing that the ulcer at its beginning is not often com- 
plicated with extensive disease of the neighbouring glands, or very 
decidedly with the cancerous cachexia. Doubtless, the probability of 
success depends much on this, and on the unimpaired health of the 
sufferer ; and although it is to be feared that the incised edges of the 
cervix may take on the same destructive action, still, favourable cir- 
cumstances existing, the operation would certainly be quite justifiable. 

CAULIFLOWER EXCRESCENCE OF THE UTERUS. 

Definition. — A morbid growth of the os uteri, consisting of minute 
ramifications of arteries, connected by a flocculent tissue, and covered 
with a secreting membrane. Its surface has somewhat of the granu- 
lated feel of brocoli, it bleeds on slight handling, and almost constantly 
pours forth a watery discharge. It varies in size, is nearly painless, 
and proves its malignancy by returning after removal, either by the 
knife, ligature or caustic. 

History, Symptoms, and Pathology. — This is a rare disease ; not 
so uncommon as corroding ulcer, but far less frequent than cancer. 
I have seen seven or eight cases, and I have operated by ligature on 
three or four. It may arise at any time after twenty years of age, 
probably earlier, if hemorrhage, child-birth, or excessive intercourse 
have previously occurred. It does not seem that temperament exerts 
any predisposing influence. Women who have not borne children, 
and virgins, are not less obnoxious to its attack than mothers, or even 
than women of abandoned habits. It differs widely from corroding 
ulcer and cancer, in the absence of pain ; nor is its progress very rapid, 
excepting where there has been great neglect, or when the sufferer is 
of unusually feeble constitution. 

Attention is first excited by the inodorous and almost constant wa- 
tery discharge. For a few weeks this may not be much regarded ; 
but its continuance, and especially its increasing quantity, and its being 
streaked with blood, produce alarm, and an opinion is anxiously sought. 
Lately, I was assured by a sufferer from the malady, that for some 
months after its commencement, she was compelled to change her 
linen twelve or fifteen times daily. Such a loss is sufficient to under- 



OF THE CERVIX AND OS UTERI. 309 

mine the strongest constitution; but even this warning I have known 
to be neglected, till hemorrhage during or after intercourse, or in the ef- 
fort to empty the bowels, had fully convinced the patient that there was 
something seriously wrong. An examination in this state will lead to the 
discovery, that there is a tumour of large or small dimensions attached 
to the os uteri, without the firm feel of polypus or scirrhus, but granu- 
lar, and communicating to the finger a sensation very similar to what 
would be imparted by the uterine surface of the placenta. There is 
considerable difference in different excrescences. The surface is not 
always granulated; if the growth be large, it loses the more compact 
feel of brocoli, and hangs in the vagina, there being a mass of shreddy 
flocculi, very loose and soft at their lower extremities, but becoming 
firmer and more solid as they approach the os uteri, from the circum- 
ference of which their growth has commenced. No pain is produced 
by such an examination, but it is rarely made without bleeding. The 
progress of the disease is exceedingly variable. In some constitutions, 
its exhausting effects are long in being realized, the losses being re- 
paired very quickly: the appetite does not fail, the strength holds out 
extraordinarily, and it is long before emaciation occurs. Still wo- 
men, even of the firmest constitutions, cannot long struggle against its 
baneful effects ; and they die, worn out by the constant drains of the 
discharge and the hemorrhage. The great majority, if the growth be 
not removed, sink more rapidly; and few* women live beyond two or 
three years from its full development. The attendant evils are much 
less than in cancer. The slight pain has been already noticed, and the 
discharge has scarcely any foetor; nor is there more tban*trivial obstruc- 
tion to the passage either of the faeces or urine. Thus, while death in 
the one disease is often preceded by sufferings which induce a desire 
for its occurrence ; in cauliflower excrescence, its approach is gentle, 
and life is gradually and almost painlessly extinguished. 

Some pathologists have doubted the malignancy of this growth, and 
have pointed to its close resemblance, at its commencement, to erectile 
tumour. They have further urged its slow progress, its shrinking and 
temporary disappearance during life, and the slight disorganization 
after death, the absence of induration and the healthy condition of neigh- 
bouring structures, and the alleged cure in one or two instances, as 
confirmatory of such a view. Still the disease returns, and after se- 
veral removals, the growth re-appears, the secretion is watery, and 
although, unlike cancer, it keeps within the limit of the uterus, it would 
not be difficult to prove, that it may become the seat of carcinomatous 
or encephaloid deposit. In a case I watched some years ago, two por- 
tions, at different times, had been removed by ligature; and on the 
third reproduction, there w T as evidently some extension of the mis- 
chief to the cervix, and I could distinctly trace carcinomatous deposits 
within its cavity. Under these circumstances, I declined any further 
operation, and death occurred in a few weeks; but, unfortunately, I 
could not obtain a view of the parts. Professor Simpson corroborates 
these opinions; and in a brief and good sketch of the malady, he makes 
the following observations: — " We have a preparation in our Museum 



310 ORGANIC DISEASES 

of the cauliflower excrescence which we removed a short time ago by 
excision of the cervix uteri. The growth has the small granulated cha- 
racter very well marked upon its surface. On rubbing a portion of the 
recent tumour between the finger and thumb, it readily broke down, 
and left a kind of vascular or cellular frame- work; but, after immersing 
for some time the mass of the tumour in an alcoholic solution of corro- 
sive sublimate, it presented to the touch and sight an appearance ex- 
actly resembling that of cerebral matter hardened by the same means, 
with the exception only of showing a number of small cells on the sur- 
face of the section." 

I have several times seen the tumour through the speculum, and its 
colour has never been exactly similar. If the examination be made 
soon after a profuse hemorrhage, it will not be of a bright- red, but of 
a pale flesh-colour; if, on the contrary, it be seen early, before the 
watery and sanguineous discharges have drained away the richer and 
colouring materials of blood, it will have a pink hue. 

All attempts to inject the tumour have failed, nor are preparations 
numerous. Some years since I lost, through the carelessness of a 
nurse, a very fine specimen, which I had removed by ligature. The 
mass was large, as, before the operation, it reached to the external 
parts; but it had entirely lost its original, distinct feel. I have never 
known the vagina implicated, nor have I seen any extension of the 
malady beyond the channel of the cervix. 

Diagnosis. — It is not difficult to distinguish cauliflower excrescence 
from hard or fibrous tumour, or from polypus; the absence of indura- 
tion and a peduncle, so characteristic of the latter diseases, and the 
softness, granular surface, and watery and sanguineous discharges,— 
circumstances almost alwavs associated with the excrescence, — will 
serve for a correct diagnosis. 

It is less easy to distinguish it from the fungoid growth of ulcerated 
cancer of the cervix. Many patients have been sent into Guy's under 
such a mistake. But even here, the absence of watery discharge, the 
previous and accompanying induration, the milder constitutional symp- 
toms, there being little pain, and instead of the irritative fever of can- 
cer, there being no more than anaemia and its consequences, point to the 
right opinion. On examination, too, the distinctness, mobility, and 
softness of the growth, and its peculiarity of origin from the os, will 
prevent error. 

It may be conceived that, where pregnancy coexists, and where an 
examination is not made till the time of labour, — supposing the patient, 
which is not likely, to have reached the full term, — there might be at 
first some trouble to distinguish the growth from the edge of the placenta. 
Where, however, there was no pregnancy, the absence of the consecu- 
tive symptoms of that state, added to the positive indications of the dis- 
ease, would suffice for the diagnosis. 

Dr. Gooch has alluded, in his usual terse and excellent style, to the 
difficulty of determining whether vaginal tumours be or be not malig- 
nant; and he says, " that he believes no man can tell infallibly by 
touch whether a tumour in the vagina is a malignant excrescence, 



OF THE CERVIX AND OS UTERI. 311 

which is to grow again, or a benign one, which, if removed, will never 
return." (Gooch, Diseases of Women, p. 308.) This is true, and yet 
he would have been the last physician to have overlooked or to have 
mistaken the characteristics of cauliflower excrescence, in reference 
to which the remark was made, and where they existed, to have given 
so questionable an opinion. If the dogma of so great a man was 
always taken in its true meaning, and induced caution only, it would 
do good ; but if carelessly adopted, it is quite as likely to prevent the 
pains-taking so necessary, and generally so efficient in the diagnosis of 
uterine diseases. Had Dr. Gooch limited this observation to the diag- 
nosis of tumours resembling cancer of the cervix, it would have been 
of greater value, because truer and more pertinent ; but, as applied to 
cauliflower growth, it wants point, as the power of reproduction, " the 
growing again" of this disease, is one of the best established facts in its 
pathology. 

Prognosis. — As to ultimate recovery, there is only the very slightest 
chance. I have never seen such an instance. But how long life may 
be protracted, will depend on original strength of constitution, and on 
the determination and means of the individual strictly to follow out 
the prescribed treatment. If the disease be early ascertained, and it 
arise from a part only of the os uteri, instead of from its whole circle ; 
if by sexual abstinence, astringent injections, regulated diet, and good 
air, the watery discharge and the bleedings can be controlled, — then 
several years, four, five, or six, may be added to life. But such steady 
attention to prescribed rules is seldom secured ; and it does not often 
happen, after removal, that more than a year or two elapse before the 
tumour grows again. The second operation takes place under less 
favourable circumstances than the first, there having been in the in- 
terval considerable draining and consequent exhaustion ; and it is by 
no means rare for fever and general debility of system to set in, and 
the sufferer soon sinks. In two of my own cases, there were nearly 
four years between the beginning of the malady and death. One pa- 
tient performed her usual domestic duties long subsequent to the opera- 
tion ; and in a most interesting instance detailed by Sir Charles Clarke 
(vol. 2d, p. 76), the disease lasted nearly ten years, two applications 
of the ligature having been made. 

Treatment. — Whether we employ palliative treatment or attempt the 
more radical cure by ligature, caustic, or excision of the cervix, must 
in a great measure depend on the extent of the disease and the feel- 
ings of the patient. The remedies to check its progress, are those 
which prevent vascular determination and congestion of the uterus, 
such as abstinence from sexual intercourse, the recumbent posture, the 
avoidance of every kind of excitement, and a mild and unstimulating 
diet. These means must be aided by an aperient, but not a purged 
state of the bowels; by the douche salt-bath over the back and shoul- 
ders ; by occasional and small abstractions of blood by cupping or 
leeching from the loins, hypogastrium, or perineeum ; by sitting in the 
cold alum hip-bath an hour morning and evening, taking the precau- 
tion to secure the entrance of the fluid into the vagina ; and by an ef- 



312 ORGANIC DISEASES 

ficient use of astringent injections.* These measures, especially the 
injections, tend to maintain and restore, the tone of the sides of the va- 
gina, and thus perhaps, by compression of the growth, its early in- 
crease may be somewhat prevented. 

It has been objected to the more radical means, that they are only 
temporarily beneficial, and that the ligature and caustic may provoke 
irritation, and thus lead to the more rapid reproduction of the malady. 
Such conditional and doubtful consequences ought not to have weight. 
Without decided treatment, life cannot be long preserved ; and there 
are many examples now on record, proving that several years, and 
these with comfort and modified enjoyment, may by such means be 
secured. 

Case 67. 
reported by dr. lever. 

JaneM , ast. 36, married, and an out-patient of Guy's Hospital, was, on exami- 
nation, discovered to have cauliflower excrescence of the os uteri of considerable size, 
without pain, and bleeding on the slightest touch. The watery discharges and the oc- 
casional hemorrhages had greatly weakened her, and produced emaciation. 

Tonics and astringent injections were ordered. During the treatment she be- 
came pregnant, but aborted at the fourth month; the hemorrhage was very profuse, 
and the exhaustion alarming. 

In six months she again became pregnant, having strenuously refused to permit 
any portion of the growth to be removed by ligature; and about the thirteenth week 
she again miscarried, suffering still greater loss of blood. From this hemorrhage 
she never thoroughly rallied, and afier lingering seme weeks, she died. 

* The following formula? are in addition to those which will be found at page 
155 :— 

K. Aluminis purif. giv. 

Tinct. Kino, giv. 

Aquae destill. ^xvss. 
M. ft. Injectio. 

R. Cupri Sulph. gr. xxx. 

Tinct. Secalis Cornut. £ij. 

Aquae destill. £xiv. 
M. ft. Injectio. 

Sir Charles Clarke. 

J&. Decoct. Quercus, ^xv, 

Tinct. Catechu, ^ss. 

Aluminis, £ij. 

Zinci Sulph. gj. 
M. ft. Injectio. 

R. Gallarum,^ss. 

Aquae destill. ^xvij. coque ad ^xvj. et adde, 

Liquoris Colati, ^xvj. 

Spir. Roris Manni, Jss. 

Aluminis, giij. 
M. ft. Injectio. 

In several of my patients, the membrane of the vagina was so irritable, that many 
hours of pain followed the use of these astringents, rendering it necessary to dimi- 
nish their strength, and to add opium, conium, or poppy. Often it will be impor- 
tant to leave them off for a time, and to inject cold water and opium after their use. 



OF THE CERVIX AND OS UTERI. 313 

Dr. Glasspool assisted at the inspection. The body seemed to have been deprived 
of nearly all its blood, and presented a most anaemiated and emaciated aspect. The 
uterus was not larger than natural, nor was there anything unusual about its condi- 
tion bpyond extreme flaccidity of structure and paleness. There was nothing remain- 
ing like the full and firm excrescence which had been so often felt in the life-time of 
the patieni ; but a loose, dirty, white, flocculent and membranous mass was found at- 
tached to the circumference of the os uteri, and to a portion of the inner membrane 
of the cervix. The pelvic olan is and the vagina were healthy. 

Case 68. 

In April, 1835, I met Mr. Callaway, and Mr. Smith of Tower Hill, 
in consultation on the following case: — 

Mrs. , aet. 40, married, and the mother of several children, had, till within 

the last two years, been remarkably healthy. During the whole of the lime she was 
having children, she had scarcely suffered a day's indisposition, and her activity and 
buoyancy of spirits had been quite remarkable. I was told, she had been very stout, 
and even now, she was by no means thin. 

Her own report is, that about eighteen months since, she first perceived unusual 
moisture about the pudendum, and slight watery discharge from the vagina; and al- 
though careless about it for a time, she was soon compelled to guard against its con- 
stant escape. She did not, however, seek medical advice, till the secretion became 
daily greater, sometimes offensive, and not unfrequently followed by eruptions of blood. 
By these occurrences she was incapacitated for her usual duties: her digestion was 
deranged, and her strength seriously impaired. There was no local pain, but sexual 
intercourse was frequently followed by hemorrhage. 

Astringent injections, tonics, a regulated diet, and other precautionary measures had 
been employed ; but after the time of my first visit, April 3d, 1835, the disease was 
daily getting worse. On examination. I found the vagina filled nearly to its entrance, 
by a growth having a broad base, and arising from a large portion of the circumfe- 
rence of the os uteri. Its surface, although rough, was not altogether granulated; it 
was much softer than polypus, and seemed to be made up of a congeries of vessels, 

held together by interposed tissue. During its progress, Mrs. said, that 

smaller or larger masses of granulated fleshy substance had frequently come away; 
but that her principal distress arose from the vast and constant escape of watery fluid 
and the frequent and exhausting hemorrhages. There was weakness of the back, but 
it scarcely amounted to pain; and the stomach had of late been so irritable, that her 
food was often vomited soon after it was taken. 

In a few days I applied a ligature round the growth ; but to my astonishment, al- 
though I tightened it night and morning, it was not till after the lapse of more than 
a week, that the flocculent mass and the canulse came away. Unfortunately this 
specimen of the disease, which was larger than a Seville orange after a shrinking pro- 
duced by its having been tied, was thrown away by the nurse, and thus I lost the op- 
portunity of preserving the best cauliflower growth 1 had ever seen. 

The sequel of the case was encouraging. The watery discharges and the bleed- 
ing did not return for nearly two years : and I have reason to believe, if proper care 
and self-denial had been exercised, a much longer period of immunity would have 
been secured. As it was, by an operation without pain or danger, life was" consider- 
ably and comfortably prolonged. 

After this* time, the exhausting losses recurred ; dropsy supervened, and the pa- 
tient died within three years of the removal. Circumstances prevented my having 
any management of the second disease, and an examination of the body could not be 
obtained. 



314 ORGANIC DISEASES 



OCCLUSION AND RIGIDITY OF THE CERVIX UTERI. 

These maladies are too frequent and important to justify their omis- 
sion from a practical work; and although the operation, which in ex- 
treme cases is indispensable, may be regarded as one entirely obstetric, 
the practical considerations justifying incision, are of a kind to de- 
mand discussion and explanation. The safety of the procedure in 
most cases of entire closure, and in some of the rare examples of ex- 
treme rigidity of the os, at the time of labour, is undoubted. It is, 
however, essential to be explicit in defining the cases where such 
treatment is required, that a rash and unwarranted use of the knife 
may be avoided; and it must also be understood, that the practitioner, 
before such a procedure is determined on, ought to be fully convinced 
that the patient's safety can be better secured by this than by any 
other method. It may, too, be observed, that the medical attendant 
should not, except when a consultation cannot be obtained, adopt the 
plan now proposed on his own responsibility. When the operation is 
sanctioned by others, should the event be unfavourable, — which will 
rarely happen if the incision be practised sufficiently early, — not only 
will the operator's own feelings and reputation be spared, but the im- 
mediate relatives of the patient will entertain no doubt as to the pro- 
priety of the practice. 

There is sufficient novelty about both the points under discussion, to 
justify the remarks I am about to make ; and if I shall succeed in throw- 
ing additional light on these perplexing cases, my purpose will be fully 
answered. Happily, entire closure, and such extreme rigidity of the 
os as to preclude the birth of a child, if help be not afforded, without 
more or less extensive laceration, are rare. Still, two such examples — 
the one of closure, and the other of rigidity — where incision has been 
successfully practised, have fallen under my observation within a short 
time. Such may again occur; and I shall therefore be excused if I oc- 
cupy a few pages in bringing the history and treatment of such instances 
of morbid structure before the profession. 
It may, I think, be shown, 

1st. That incision is the safest remedy, where the os is in a state of 
firm and complete closure; or, in other words, where the uterus, so far 
as its lower orifice is concerned, is imperforate: and, 

2d. That in examples of such extreme rigidity of the os, where, 
after hours of strong uterine effort, the power of dilatation is entirely ab- 
sent, whether such rigidity arise from disease in the structural organi- 
zation of the part, or has resulted from previous laceration and ulcera- 
tion, incision is the best and safest treatment; far preferable td protracted 
and powerful dilatation of the os by the finger; or, on the principle of 
non-interference, to leaving the case to the natural efforts. 

Examples of the entire closure of the os uteri at the time of labour 
are recorded by Dr. Naagele, junior, in his Thesis on " Conglutination 
of the Os Uteri," published at Heidelberg in 1835. And there is no 
paucity of allusion to them by other writers. It is well known, that, 
normally, this orifice is sometimes very small; at others, instead of a 



OF THE CERVIX AND OS UTERI. 315 

transverse chink — its most usual form — there is merely a diminutive 
circular aperture. In either of these conditions of the orifice, complete 
obliteration may easily be produced, by an amount of local inflam- 
mation following conception, which would not seriously interfere, 
either with the pregnancy or the health of the individual. It is impor- 
tant to bear in mind, that such closure may not be attended by any 
other disease of the parts : the adhesion maybe firm and complete, 
but there may be no scirrhous induration — no distinct nodule of hard 
substance ; the neck of the uterus will be forced down by the pains ; 
and the sensations imparted to the finger, on examination, during labour, 
will be quite natural, excepting only that no aperture will be found. 
There is therefore a marked difference, so far, between the cases of 
closure occurring as the result of adhesive inflammation, where the 
orifice is naturally unusually small, and the instances of occlusion 
which are the consequences of previous morbid deposit about the os 
and cervix, produced either by chronic inflammation, or occurring as 
the result of former laceration or ulceration. In the latter class of 
cases, where there is evident organic disease of structure, a long delay 
in the employment of venesection — and of the incision, if the bleeding 
fail — is not probable ; whereas in the cases of simple but firm closure, 
where there is no other disease, delay is far more probable. It will 
be urged as extremely unlikely that there should be no os uteri ; — 
that there is one, perhaps, but that, owing to obliquity, it is very high 
up posteriorly; — and that, being thus unnaturally situated, twenty-four, 
thirty-six, or forty-eight hours, or even a longer period, will be re- 
quired for its development and dilatation. The unfortunate instances 
of occlusion recorded by various authors may be attributed to this very 
delay ; and they show how necessary it is that every circumstance 
should be explained, and if possible removed, which may tend to mis- 
lead in a newly-observed and hazardous malady. Mr. North dwells, 
at great length, on malposition of the womb ; and does not hesitate to 
express his belief, that most of the reputed instances of imperforate ute- 
rus were really nothing more than cases of anterior obliquity ; and the 
names of Baudelocque, Desormeaux, Velpeau, Denman, and Dewees, 
are adduced as holding these opinions. For myself, I may say, that 
I have never met with any seriously protracted labours from obliquity ; 
and I think I could mention many highly respectable writers, whose 
experience corresponds with my own in this particular. Allowing, 
however, to this supposition its full weight, it must be recollected, that 
every hour of urgent uterine effort tends to rectify obliquity, if such 
be the cause of an undiscovered os uteri ; and that if the pains are 
really powerful, and protracted for ten or twelve hours, the os uteri 
being still undiscovered, it may fairly be assumed that it is wanting, 
and it is time then to think of the dangers of uterine rupture and lace- 
ration. So far as my case and its continuation, so correctly reported 
by Mr. Tweedie,* can illustrate this point, it may be cited as an ex- 
ample of the facility of diagnosis, and of the safety of the treatment 
by incision. The error of the first operation consisted in its delay. 

* See Guy's Hospital Reports, vol. ii., p. 258. 



316 ORGANIC DISEASES 

From anxiety not to incise the uterus, if it could be avoided, the woman 
was permitted to incur more risk than was justifiable ; and from the 
excitement and fatigue of the labour, the collapse was alarmingly dan- 
gerous ; much more so than after the second operation, when, confirmed 
in a favourable view of incision by its previous success, the division 
of the parts was earlier resorted to, and the collapse was proportionally 
slight and transient. 

There can be little difficulty in the diagnosis of instances of com- 
plete and firm closure of the os. When parturient effort is really es- 
tablished, the lower N portion of the uterus, in the form of a tense and 
large globular mass, is generally forced down very low, sometimes 
so far, as nearly to reach the external entrance of the vagina. Thus, 
a finger — if at all practised in these inquiries — detects an aperture, if 
there be one : and, if not, the spot where the os uteri, at the time of 
conception, had been. 

A repetition of uterine action will aflbrd abundant opportunities for 
careful re-examination, so that no apology for indiscreet and danger- 
ous delay can exist. If, too, a spot shall be discovered— more de- 
pressed, and of different structure to the surrounding parts, indicating 
the site of the os uteri at the time of impregnation, it is impossible 
then to doubt about the nature of the case ; and the only question re- 
maining to be determined, is the precise method of relief. 

It may be a matter of hesitation, whether bleeding to some extent 
— say, eighteen, twenty-five, or thirty ounces — should not precede the 
use of the bistoury. 

In some critical remarks on my own case, in the " British and 
Foreign Medical Review," Vol. III., page 375, the writer says:— 
"Under the circumstances, we believe the incision into the cervix 
was justifiable ; though we think it not impossible, that, had a free vene- 
section been premised, and some further time given, an os uteri might 
have been found." From which opinion I entirely dissent. 

Practitioners should be extremely cautious on both the points now 
alluded to— I mean, bleeding and delay. It would be difficult to jus- 
tify a large venesection in cases of closed os, like those now described, 
where there was no other disease about the parts than the occlusion : if 
there were malignant deposit, a general scirrhous induration of the 
cervix, or cicatrices of cartilaginous hardness, the abstraction of blood 
in a case thus complicated would be highly judicious : and certainly, 
if there be so much doubt resting on any case, as to leave it a matter 
of question, whether there,be an os uteri or not, venesection and delay 
are less censurable than the continuance of the doubt and uncertainty. 
If, however, the practitioner has decided that there is an occluded os, 
without other disease, and that the head of the child cannot pass till a 
way be made for its transit, nothing else than exhaustion and danger 
are to be anticipated from bleeding and delay. 

I purposely avoid, in this place, more than allusion to those cases 
of occlusion of the os uteri complicated with marked and decidedly 
morbid altered structure. These examples are so closely connected 
with the cases of extreme rigidity, and so generally arise from the 
same causes — viz., organic disease, and the injuries or lacerations of 
previous labours — that it is quite proper to place them together. 



OF THE CERVIX AND OS UTERI. 317 

Having abandoned all hope of discovering an os uteri by venesec- 
tion and delay, there are two methods of remedying the closure of this 
important orifice: — 

1. By such an amount of pressure by the finger, female catheter, 
sound, or bougie, as shall puncture or open the occlusion; and, 

2. By incision, made by a bistoury or knife. 

Dr. Naegele, junior, of Heidelberg, advocates the first of these plans, 
and condemns the use of the knife, except as a last resource, other means 
having failed. Dr. Waller has, in Vol. IV. of Guy's Hospital Reports, 
furnished a case so treated. 

When the occlusion is slight, depending on a thin membrane inter- 
posed between the margins or filling up the circumference of the 
os, similar to the membrane found between the adherent labia of fe- 
male children, the finger, as recommended by Naegele, may produce a 
separation or orifice; or if this digital pressure be insufficient, the ca- 
theter, sound, or bougie may enable us to accomplish our purpose. It 
may now be expected, if the structure of the cervix be healthy, that 
dilatation of the os will proceed as satisfactorily as in many cases where 
this orifice is naturally small. In such we rarely find the power of di- 
latation absent. 

Naegele proves, in examples of conglutination, that the finger alone 
will succeed. His reasons for preferring the digital puncture to the knife, 
are given in the following quotation from his Essay: — 

1 ' Conglutinationis orificii uteri sanatio in quam piurimi.s casibus nullis 
obnoxia est difficultatibus. Aut digito aut instrumento satis obtuso, e. 
g. cathetere femineo, digito duce in vaginam immisso et orificio uteri 
leniter adpresso conglutinatio, sine ulla parturientis molestia, facile dis- 
rumpitur: plerumque nonnullae sanguinis guttulae inter operationem ef- 
fluunt, testes materiam organicam operatione ruptam esse. 

'Digitum autem ad operationem perficiendam instrumento praeferen- 
dum esse censeo, turn quia ad destruendam conglutinationem plane suf- 
ficit, turn quia digito adhibito minus timendum est, ne ovi membranae 
laedantur; turn quia si digitus non sufBcit, ab instrumento obtuso aux- 
ilium vix exspectandum erit. 

"Hanc autem medendi rationem operationi per incisionem praefe- 
rendem esse, nemo certe in dubium vocabit; quanquam enim incisio 
a manu perita et caute instituta non omnino periculosa est, cum expe- 
rientia uterum satis graves laesiones sine infelici successu tolerare do- 
ceat; negari tamen nequit, incisione ab homine in arte chirurgica minus 
perito facta, utique deploranda parturienti inde evenire posse mala. 
Nonne enim, e. g. bulla aquarum incisione laesa, dolorum vi subito 
jam aucta, caput foetus fortiter descendens ipso instrumento vulnerari 
potest?" 

But Naegele's method of procedure is clearly inapplicable where the 
interposed cellular membrane, shutting up the os, has become tho- 
roughly organised and firm; so much so, indeed, as effectually to 
have resisted twelve, twenty, or thirty hours of most urgent uterine 
effort; although I am quite aware, that neither the wedge-like dila- 
ting property of the membranous pouch, containing the liquor amnii, nor 



318 ORGANIC DISEASES 

the head of the child, supposing it to present, can be brought fairly to 
bear upon the closed os owing to the occlusion. 

Nor must it be forgotten, if the finger or catheter be forcibly used to 
make an artificial os, that the parts would be contused, and that there 
would probably ensue, after such contusion, local, if not general ute- 
rine inflammation. If this be the result, the chances of recovery are 
greatly diminished. 

It may too, perhaps, be fairly assumed, that the risk of unlimited lacera- 
tion of the uterus and adjacent parts is much less, where incisions of 
tolerable extent havebeen discreetly made, than where merely a dimi- 
nutive central aperture has been formed by a blunt instrument. In Case 
69, after four operations* — and in others, where incision was practised 
— the subsequent lacerations were confined to the cervix; they were re- 
strained within the limits of the reflection of the mucous membrane over 
the neck, and did not involve the peritoneum, the body, or fundus of 
the womb. As of additional weight, it may be stated, that the struc- 
ture into which the incision was made, was not the structure of the cer- 
v ix — f or it was clearly ascertained afterwards that a cervix did not exist 
— and although in both instances the incisions by the knife were fol- 
lowed by rent, yet in neither did those lacerations extend beyond the 
lower segment of the uterus, included within the reflection of the vagi- 
nal mucous membrane. 

I proceed now to the second part of this subject, — in treating of 
which, I shall prove, from the similarity of cases of excessively rigid 
and undilatable os uteri to those of occlusion, as well as from the ex- 
perience of the operation itself, that, in many such cases, incision may 
be safely and advantageously, if early practised. It must not be sup- 
posed that I recommend the knife to be at once employed in these 
more complicated maladies; but I am confident — so far, at least, as it 
is possible to be confident, in cases where probability must be our only 
guide — that where fatal results have occurred, they might often have 
been prevented by timely incision of the parts. But it has too often 
happened, as the appended cases show, either that the operation has 
been performed too late, or that a too powerful dilatation by the fin- 
ger, and an unwise reliance on the natural efforts, have altogether su- 
perseded its employment. Examples of entire occlusion without dis- 
ease, like those to which I have already alluded, are much more rare 
than extreme rigidity of the cervix and a diminished os; nor will it be 
found quite so easy in the latter as in the former class of cases, to de- 
termine the precise moment when bleeding, diaphoretics, fomentation, 
and delay, are to yield to the use of the bistoury; still the general 
safety of incision, and the known and imminent danger of protracted 
and severe uterine effort and contusion, ought to induce an early 
rather than a deferred operation. A careful perusal of the cases and 
authorities appended, especially Smellie's, cannot fail to impress this 
conviction. In every instance, or nearly so, where the division of 
the morbid structure has been made, prior to the occurrence of in- 

* It is remarkable, that in all the labours of this patient, now amounting to four, 
all of them being managed by different practitioners, incision has been necessary, and 
only a limited extent of laceration has occurred. 



OF THE CERVIX AND OS UTERI. 319 

flammation and sinking, it has succeeded ; and, generally, with the 
fewest possible bad symptoms. Where, on the contrary, violent ute- 
rine action, contrary to the sagacious directions of the experienced 
Dr. Hamilton, has been allowed to go on for a great number of hours 
— say twelve, fifteen, twenty-four, or even a longer period — the result 
has generally been unfavourable, often fatal ; and still more certainly 
so, where, during a portion of this time, powerful dilatation has been 
long and forcibly employed. Dilatation by the finger is not the same 
operation here, as to safety, which it is found to be in examples of 
rigidity not dependent on, or associated with, local or structural ma- 
lady. It is true that, in transverse and placental presentations, artifi- 
cial dilatation is often practised with safety and advantage. Neither 
the mouth nor neck of the womb, both being healthy, suffer from the 
process : prevention of hemorrhage, and a freedom from useless and 
exhausting pain, are the results of the process; but where the cervix 
is rigid, contracted, and diseased, and the os so small as scarcely to 
be recognised, powerful and long-continued artificial dilatation must 
be a dangerous remedy. It is scarcely to be expected that it should re- 
lax the parts and lead to dilatation ; it is much more likely that it 
should irritate, and thus induce inflammation, gangrene, and death. I 
have said, that cases of entire occlusion and excessive rigidity have 
points of resemblance; but it must also be borne in mind, that they 
present important and marked differences. 

The simplest, perhaps, of the examples of rigid os uteri, is where a 
very contracted orifice is surrounded by a structure almost entirely 
undilatable. In such a case, although there may be a little indication of 
organic change, still, if there be a total absence of the power of dila- 
tation, after the use of free venesection and antimony — time having been 
allowed for their beneficial effects — such a case cannot be long trusted 
with safety, either to the natural efforts or artificial dilatation. Other 
examples are not so simple as this. Many, probably the majority, 
are the consequence of some previous morbid occurrence. The os 
and cervix may have been injured in a former labour ; abscesses, ul- 
cerated surfaces, and cicatrizations may have taken place ; thus the 
uterine orifice may have become nearly, if not entirely, closed ; and 
the relative situation of the urethra, bladder, and vagina, so altered, 
as to render the division of parts much more difficult and hazardous ; 
or it may be, that a hard tumour, or a more malignant and active de- 
posit, has imbedded itself in these parts, totally altering the os and 
the natural structure of the cervix. In one essentia] particular, all 
these varieties will be found to agree, viz., in the difficulty with which 
the os and cervix are dilated ; while in some, and those not a few, the 
susceptibility of dilatation will have been entirely destroyed. 

Supposing, then, that the incapability of dilatation is satisfactorily 
established— what is to be done ? We are presuming that the disease 
is well understood pathologically ; that bleeding and every adjuvant 
remedy have been fairly tried, but without success. 

The case may then be treated by artificial dilatation or by incision ; 
or it may be left to nature. To adopt the last course, would be to con- 
sign the patient, most probably, to unlimited laceration, if the womb 



320 ORGANIC DISEASES 

continued to act ; or to death, without laceration, if, worn out by pro- 
tracted yet fruitless uterine pain, inflammation should take place. 

Of artificial dilatation, enough, perhaps, has been already said, to 
indicate how little confidence in such rigidities can be placed on the 
utility of a moderate stretching of the uterine orifice : and certainly no 
impression can be derived from the appended cases favourable to pro- 
tracted and powerful artificial dilatation. 

It may then be assumed, that we are not justified in protracting the 
employment of the knife till the patient is nearly exhausted by the con- 
tinuance and severity of the expulsatory efforts ; the indications of ap- 
proaching collapse being apparent, in a quick and feeble pulse, a cool- 
ing surface, hurried and short respiration, a subdued tone of voice, a 
tender and tympanitic abdomen, and a gradually-diminishing uterine 
pain. Many instances are on record precisely of this kind ; and the 
event, in nearly all, proved fatal. Nor ought we to hesitate about in- 
cising the cervix, where the violence and frequent return of the uterine 
effort threatens rupture of the womb. If there be distressing and con- 
stant pain about the neck or body of the uterus, or in any other part ; 
if the countenance become turgid and dark ; if perspiration issue at 
every pore, and the pulse be full, strong, quick, and incompressible ; 
and if these symptoms continue, although perhaps somewhat lessened 
by bleeding and antimony, there can be no doubt that recourse should 
be had to incision. It is impossible to fix a precise limit during which 
a patient may be safely left to unaided efforts : time is not the only 
condition, although an essential one in every rule regulating interfe- 
rence in obstetric cases. 

There can be no doubt that, in many instances of rigidity, a free 
abstraction of blood, the exhibition of ^-, J, or \ gr. every hour of 
tartarized antimony, with or without opium, till it produces nausea, 
will accomplish the dilatation. No sensible practitioner would feel 
himself warranted at once to propose incision ; nor would such an indi- 
vidual consider himself justified in not performing it when other means 
had failed. While, on the one hand, 1 am anxious to avoid the impu- 
tation of rashness, I am, on the other, if possible, more desirous to 
avoid the imputation of timidly shrinking from a procedure absolutely 
essential to a patient's welfare. 

The operation, in any of the cases, whether it be on an os firmly 
closed, yet without organic change — or on an os very diminutive and 
contracted, with or without surrounding disease, but entirely undilatable 
— is, generally, easily performed. A probe-pointed knife or bistoury 
is the instrument most safely used ; the patient lying, either on her left 
side or on her back, close to the edge of the bed. The forefinger on 
the left hand is to be carried to that spot of the cervix intended to be 
cut ; afterwards, the knife or bistoury is to be cautiously conveyed 
along the finger in the vagina, to the spot already mentioned ; and if 
its point be gently pushed against the uterine structure, it will com- 
pletely incise the parietes. In Case 69, I carried the knife, first of all, 
forwards, towards the neck of the bladder (which was empty), care- 
fully avoiding it ; afterwards towards the sacrum, making an incision 
about two inches long. The liquor amnii will necessarily escape, as 



OF THE CERVIX AND OS UTERI. 321 

soon as the first incision is made. The instrument may now be care- 
fully withdrawn, and the further dilatation left to nature. It is scarcely 
to be expected that all rending should be avoided ; but the extent of 
the tearing is, as has been already stated, generally confined within the 
limits of the vagina. I have no experience of the better effect of a 
crucial incision in preventing extensive laceration; but lam favour- 
ably inclined to it. It is not probable that much blood will be lost 
during or after the operation; in my own cases, only a few drachms 
escaped. If there should be fainting and collapse, after the incision of 
the parts, brandy and ammonia may be freely exhibited. It is a neces- 
sary preliminary step that the bladder and rectum be emptied of their 
contents. In Case 69, the birth of the child was four times accom- 
plished without instrumental aid; but the forceps is not unfrequentlv 
necessary to terminate the labour. 

I shall now give a brief summary of the most important circumstances 
01 some of the various recorded examples of occlusion and rigidity, in 
which incision was or ought to have been practised. 



CASES OF ENTIRE OCCLUSION. 



Case 1.— Mrs. P.'s. (See Guy's Hospital Reports, Vol. II. page 258.)— Here the 
patient, prior to the incision of the neck of the uterus, had been in stroni labour for 
twenty-nine or thirty hours. 5 

Jn^tltt di T lsio " with a sharp-pointed bistoury, not having a blunt-pointed in- 

TfZT I Dd ;M Th / re Wa f SCarCe y ™* pain com P^e° off and not more than 
a few drachms of blood were lost. Although there were two or three lacerations after 

deli p-v i "' Ti ^^ a,armm ° C ? lapSe ' the natUral efforts were anient ^r the 
deliver, and the patient recovered quickly and well. The child, although some 

what asphyxiated at birth, rallied. Length of incision about tl' inches^ I 'this 
had^no r7 S le atI SCt0r aSC6rtained that there was no cervix 5 and the left mamma 

published 2 \ a 8 n 3 d 5 3 ^ Exam P les taken from the Thesis of Dr. Neegele, junior, page 19, 

d„ipH b °hl h ' 'if T Uterl ? aS ' no J, mall y' exceedingly small; and the occlusion was pro- 
duced by cellular membrane filling up the orifices. The lower part of the uterus 
was rendered very tense and hard, and greatly pushed down by the uterine efforts; so 
mat, in one of the cases, it might with some excuse have been mistaken for the baa- 
or membranes containing the liquor amnii. In Case 2, the patient was fat and ple°- 
thonc ; and so violent were the pains, that although she had been bled four times 
no pain occurred without hemorrhage from the mouth and nose. It appears that she 

Z S T%T ! T m Iab0Uf f ° r 6 > ht da * S t matrona q-"^* plethorica P et sat ob sa 
Verocto dies vehement.ss.m.s ad partum doloribus agitabatur, ita ut sanguis ei e Pa- 
ribus et ore erumperet, quanquam jam quarta vice ei vena secata erat). °I n Case 3 
the patient had been in labour two days\nd nights. A female catheter was used in 
both these cases, to accomplish the puncture. In both, the uterine orifice dilated 
(confirming the opinion already expressed), not only without laceration but w'h 

ZZ \uZT am ° Un ? f del , ay ' The force P s was not re ^red in either ; and a 
both, the children were born alive and healthy. 

These are instances, not of very firm and organised closure of the 
os but of conglutination effected by a slight cellular membrane— « ope 
telee filamentosce;" the finger, or the catheter, would therefore sue- 
ceed. 



322 ORGANIC DISEASES 

Case 4.— (From Dr. Nsegele's Thesis, p. 27.)— On 17th of August, 1822, Dr. 
Meissner, of Leipsic, was called to a patient, thirty-five years of age, in her second 
labour. The pains were first felt on the 14th of August, and they had increased on 
the succeeding day. The midwife, on examination, detected the head of the child, 
but could not discover an os uteri. A surgeon was then called ; and although he 
urged the patient to bear down when the pains occurred, by which the lower seg- 
ment of the uterus was pushed very low in the vagina, still he could not discover 
any uterine orifice. 

At noon, on the 16th of August, the woman was so exhausted, that she was unable 
to make any further voluntary^efforts. although she still complained of the urgency of 
the pains. In the evening, the pains were less frequent and strong; and during the 
night, she was delirious. In this state, Dr. Meissner first saw her, on the morning of 
the 17th of August. The pulse was small, quick, and intermittent; and the patient 
was exhausted and worn out. The head of the child was entirely covered by the in- 
ferior portion of the uterus, much stretched and attenuated ; and although the globu- 
lar mass was pushed almost to the lower orifice of the vagina, there was to be found 
no vestige of an os uteri. Dr. Meissner, convinced that the uterine orifice was oc- 
cluded, determined on the propriety of making an artificial opening. He did this with 
a scalpel ; and, by the forceps, brought into the world a dead child. At nine o'clock 
in the evening the patient died. 

It is not possible to conceive a case that could more entirely verify 
the opinions I have already advanced. The occlusion here seems to 
have been as firm as in my own case; and we must deeply regret that 
the operation was not performed at the expiration of twenty-four hours, 
instead of at the end of nearly three days. 

Cases 5 and 6. (From Nssgele, p. 28.) Examples of occlusion of the os uteri 
produced by membranes filling up the orifice, and uniting the margins of the aperture. 
In one the pressure of the finger was sufficient to rupture the membrane. In the 
second, the point of the femalecatheter was used. In both, parturition was accom- 
plished without instruments. The children were living at the time of birth, and both 
the mothers did well. 

Case 7. (From Naegele, p. 32.) This case was managed by Dr. Rummel. The 
labour commenced on the 25th of August, 1822. The patient was pregnant for the 
first time, and had suffered from leucorrhoea during the whole period. 

There was no os uteri, and on the 27th of August, Dr. Rummel made one, by inci- 
sion. Six hours afterwards he applied the forceps, and brought into the world a 
living child. The patient recovered well. The orifice retained afterwards the form 
it had received from the incision; and in the next confinement there was no necessity 
for further interference. 

Case 8. (From Neegele, p. 35.) Here the patient was forty-two years old, and 
in her first pregnancy. The labour commenced on the 2d of May; and Dr. Solera, 
after repeated examination, was unable to find an os. On the 4th, in the presence of 
other medical men, an incision was made into the neck of the womb; and in twenty- 
two hours afterwards, the child was brought away by the forceps. 

Case 9. A fatal example of complete occlusion at the time of labour, the patient 
having previously borne several children. Dr. Waller, of Bartholomew Close, fur- 
nished the case to the late Mr. Tweedie ; and a full account of it will be seen in Vol. 
II. of Guy's Hospital Reports. 

Case 10. (Reported in Dr. Gooch's published Lectures.) After miscarriage, ex- 
tensive sloughing took place, comprehending the os uteri; in place of which there 
was only a hard contracted circle, as if foimed by a cicatrix. This woman was at- 
tended in her labour by three surgeons; all of whom agreed in the fact, that the os 
uteri was lost. The labour-pains were not sufficient to force the head through this 
unyielding portion of the passage ; the head had descended low into the pelvis, push- 
ing the lower part of the uterus before it. After waiting a considerable time, and 



OF THE CERVIX AND OS UTERI. 323 

the strength of the patient being almost exhausted, it was determined by the pro- 
fessional attendants, to cut an os uteri. The patient was taken out of bed, and placed 
in the position for lithotomy ; so that the light fell on the vulva. By dilating as much 
as possible the externa! orifice, the cervical portion of the uterus was apparent, as 
well as the cicatrix in the situation of the os uteri. This part was first punctured 
with a sharp-pointed bistoury, and an incision of considerable extent was then made 
with Pott's bistoury. The patient was replaced in bed ; the labour-pains returned; 
and the head was forced through the opening, rending it right and left. Some 
alarming symptoms now occurred; and as the head descended slowly, it was perfo- 
rated, and she was speedily delivered. In forty-eight hours after her delivery, this 
woman had no bad symptoms. There was a purulent discharge from the vagina 
for about a fortnight, after which she recovered perfectly, and is now pregnant 
again. 

Dr. Gooch adds : — " Many similar cases which were treated in the same manner, 
have been recorded ; some of them terminated successfully, and others fatally, incon- 
sequence of the operation having been too long delayed." 

It would be superfluous to add more such cases as these. They 
abundantly establish the opinions formerly advocated, and the treat- 
ment recommended ; and every practitioner may increase his infor- 
mation on this interesting subject, by a careful examination of the au- 
thorities which support these views. 



CASES OF CONTRACTED OS UTERI, COEXISTING WITH EXTREME 
RIGIDITY OF THE CERVIX, DEMANDING INCISION. 

Case 1. (For its complete history, see Guy's Hospital Reports, Vol. IV.) A con- 
tinuation of Mrs. P. 's case- Incision was practised: there was some rending of parts, 
and collapse. The mother and child both did perfectly well. In two subsequent 
labours, treated, the one by Mr. Armstrong of Gravesend, and the last by Dr. Lever, 
incision has been performed with the same satisfactory results. 

Case 2. The following history demonstrates the inexpediency of strong artificial 
dilatation and delay. There can be scarcely any doubt but that recovery would 
have followed an early incision It is, however, very instructive. 

To-day, August 6, 1831, 1 visited Mrs. R , residing in Spitalfields. She is 

thirty-one years of age, has been confined only two days, and is dying from peritoneal 
inflammation. I ordered ammonia and wine, together with a mustard poultice over 
the hypogastric region. The slightest pressure on the abdomen produced exquisite 
pain : pulse 148, weak, fluttering, and intermittent. Two days afterwards I in- 
spected the body, Mrs. R having died shortly after my visit. 

1 was informed by the medical attendant, that the os was extremely rigid ; and that 
having waited nearly twenty-six hours for its dilatation, he had stretched it artificially 
by the finger; and although he had done it gently, she complained severely of pain 
both at the time and afterwards. The attempt at dilatation occupied upwards of two 
hours. 

An examination after death showed the peritoneum to be generally inflamed, but 
especially the portion of it investing the uterus: there was a considerable quantity 
of dark-looking serum, tinged with streaks of blood in the pelvic cavity ; and floating 
in this serum there were many shreds and patches of coagulable lymph. On di- 
viding the uterus from the fundus, downwards, the whole of the cervix, and much of 
the lower portion of the general cavity of the uterus, was found to be in a gangre- 
nous state. The upper part of the vagina was inflamed and also gangrenous. 

Case 3. — (See Smellie's Cases, Vol. III., p. 43.) As this case is very long, 
although interesting, I must refer the reader to the work in which it is contained, 
giving only the leading particulars. 



324 ORGANIC DISEASES 

It was under the eare of Dr. Simpson, Professor of Medicine in the University of 
St. Andrew's. 

The patient was observably narrow between the ossa pubis and the os sacrum; 
and the growing together of the sides of the os uteri, leaving no vestige of a passage, 
was the result of mischief occurring in a former labour, which lasted four days, and 
was eventually completed by the perforator. A plentiful suppuration from the inter- 
nal parts continued for a time after the first labour. 

Dr. Haddow confirmed Dr. Simpson's opinion of the case. Two days having now 
elapsed, it was determined to cut an os uteri ; but it was thought necessary, in order 
that the incision might be more securely made, that the vagina should be first di- 
lated. This being completed, the cicatrix of the united parts was distinctly seen : 
and it was divided by an incision, at least half an inch deep. The child's head was 
then touched, and the whole circumference of the passage was found to be hard, like 
a cartilage, not at all yielding to several throes she had after the incision. "So that 
I was obliged," says Dr. Simpson, " to guide a narrow-bladed scalpel with my finger, 
and to make several incisions into this cartilaginous ring. The labour continuing, 
the passage dilated a little, but not so much as to give any hopes of its allowing the 
child's head to pass, notwithstanding the bones of the cranium were over-lapped ; and 
therefore I was obliged to bring away the child by perforation." 

"My patient," says Dr. Simpson, " immediately after being put to bed, was seized 
with a pleuritic pain, very high fever, and difficult breathing; which, coming on so 
soon after her being fatigued several days with hard labour — -during which she slept 
none, but drank much — appeared to me rather the cause of her death in twenty-four 
hours after, than any consequence of the incision I had made; for she never com- 
plained of uneasiness in those parts, nor had she any hemorrhage." 

There can be little doubt that the contusion of the parts, and the 
collapse of the system consequent on the two days of prolonged la- 
bour, prior to the incision, induced the fatal result. Nor does it ap- 
pear that bleeding, so likely to have been highly beneficial, was prac- 
tised ; at least, there is no allusion to it in the narrative of the case. 

Case 4. (Smellie's Cases, Vol. III., p. 204.) This is a painfully instructive 
history. First of all, repeated and powerful attempts were made to dilate the os, 
not alone by Dr. Smellie, but by others also. Instruments were passed into the 
mouth of the child, with the same intention ; and although considerable efforts were 
thus made, the dilatation could not be accomplished. Flooding and faintness were 
the consequence of these measures. " But," says Dr. Smellie, "after she was re- 
cruited, I tried again to dilate the os uteri; having found, in other ^ases, that it di- 
lated easily when the patients were faint and weak ; but I found the same difficulty 
as before." 

"I was apprehensive," says Dr. Smellie, "of using any greater force by pushing 
up, lest I should tear the uterus from the vagina; but finding that I could not fix 
the crotchet to advantage, I again withdrew it. All this time the os uteri felt as if it 
was two inches thick." Mr. Burnet, who had first seen the case, again attempted 
to dilate, even after this period, but without success. She died soon afterwards, in 
a convulsion, undelivered. 

Here,, again, it does not appear that bleeding was practised. The 
case requires no comment ; venesection, and the incision, would pro- 
bably have saved the patient. 

Case 5. (Smellie's Cases, Vol. III., p. 211.) This is another instance of the same 
unfortunate kind, although here Smellie approached to the right treatment. The 
os uteri was open to about the size of halTa crown, but rigid anrfvery thin: it was a 
first labour, and occurring two months before the full time. 

After continued and unsuccessful efforts to dilate the rigid orifice, Smellie incised 
the neck of the womb by a pair of scissors : the parts afterwards gave way ; the hand 
was introduced ; and a dead child was brought away by turning. 

There was much flooding; and the patient died on the fourth day. 



OF THE CERVIX AND OS UTERI. 325 

Case 6. (Dr. Neegele's Thesis, p. 17.) Here the patient was a healthy country- 
woman, of 35 years of age. On examination, a very small aperture or orifice was 
found, from which there issued a^brown mucous fluid. Various attempts were made 
at dilatation and delivery, but without success; and after two days of useless and 
protracted uterine suffering, the patient died. After death, there was discovered a 
very large rupture of the uterus. 

I might increase the number of these cases ; but it is unnecessary to 
do so, as this treatment has now received the sanction of some of the 
best obstetric writers and practitioners ; and, I am persuaded, renewed 
trials will only confirm its value and safety. 



As references to some of these examples of successful incision in 
rigidity may be useful, I append them. In the Volume of the Medi- 
cal Gazette for 1837, p. 585, I have detailed an instance where, in 
two succeeding labours, it was necessary to incise the os. Crucial 
incisions were made in both operations. In the first, perforation was 
resorted to. In the second, the forceps only was employed ; but the 
child died. This patient has subsequently borne three living children; 
no further division of the uterus having been required. 

In Professor Davies's work on operative midwifery, some valuable 
observations on rigidity will be found. He is fully aware of the value 
of bleeding as a remedy for, or corrective of, an actually existing 
rigidity ; nor does he deprecate artificial dilatation, in some cases, if 
employed with caution. 

Several very interesting cases are recorded of the success attendant 
on timely incision ; and one is quoted from Tretzelio, where fatal rup- 
ture of the uterus occurred, from non-dilatation of its orifice ; in which, 
although severe labour lasted for nearly three days, no attempt of an 
efficient or decisive character was made to avert the calamity. In 
another example, the patient was forty years old, and pregnant with 
her first child ; she had been in strong labour for three days, and suf- 
fered convulsions during the second. She was frightfully pale : her 
pulse was almost extinct, as well as her voice, yet the circumference 
of the orifice of the uterus, open to the diameter of a crown piece, 
was hard, tight, and, in a manner, callous. Delivery was performed 
spontaneously in three or four minutes after the section of the part : 
the child was dead, but the mother immediately grew calm, and the 
subsequent symptoms were mild. 

Heath's translation of Baudelocque, Campbell's Midwifery, and va- 
rious journals, may be consulted for further information. , 

Dr. Davies very properly refers to the forceps and turning, as im- 
portant remedies, where the incision may have been succeeded by a 
profuse hemorrhage, or having been too long delayed by an inability 
to effect spontaneous delivery. If the head has advanced far into the 
cavity of the pelvis, the forceps must be resorted to ; if, on the contrary, 
it be still at or above the pelvic brim, the hand, being of softer texture, 
and itself endowed with feeling, would be the safer instrument. 

Mr. Godfrey, formerly a student of Guy's, informs me, that recently 



326 ORGANIC DISEASES 

in Paris, M. Paul Dubois incised successfully in a case of occlusion of 
the os, after the employment of opium. 



Case 69. 

PREGNANCY WITH IMPERFORATE UTERUS. 
REPORTED BY MR. TWEEDIE. 

Eliza P , aged 23 or 24, an Irishwoman, residing at No. 105, Little Suffolk 

Street, Southwark, a patient of Guy's Lying-in Charity, was taken in labour, with 
her first child, on the 14th or 15th of November, 1836. Mr. Roe, the gentleman to 
whom the case had been intrusted, was called to her at seven o'clock in the morn- 
ing. He was informed that she had been in strong pain since the preceding evening, 
but there had been no show as yet. Mr. Roe observed the pains to be urgent and 
very powerful; but although he remained several hours with her, he had not suc- 
ceeded in discovering the os uteri. 

Puzzled with such a novelty (for he had attended a great number of confinements), 
he requested me to visit her. It was now two o'clock : the patient was on her bed. 
On examination, 1 found a firm, uniform, globular mass forcing down into the vagina 
at every pain (which was of great force), but no irregularity upon its surface could 
be detected ; and a very careful examination of the entire vagina, whose extremity 
was easily reached at all points, failed in detecting the os uteri. As her bowels had 
been confined for two days, Mr. Roe had administered a dose of castor oil ; so we 
delayed a few hours, to see what nature would do, as well as to afford time for the 
oil to operate. 

In the evening we again met, and saw the patient. Labour-pains had persisted, 
and were of unusual severity; the castor oil had acted once. A most careful inves- 
tigation of every part of the vagina failed to detect any os uteri. At the upper part 
of the canal, at each pain, there was forced down this tight, tense, globular body, of 
the bulk of the child's head ; and conveying the impression of an entire uterus, 
without orifice. 

About the spot where the os uteri should have been, was a minute portion, some- 
what, thinner than the surrounding parts; but the whole was uniformly smooth, and 
contained no break whatever. 

On the receding of the mass, in the absence of the pain, something like a child's 
head could be felt within. 

Inquiries were now made, and the following facts elicited : — 

Mrs. P was married on the 4th of February preceding, 1836. Since the 

age of fourteen, she had menstruated every four weeks, sometimes every three 
weeks. The discharge was always pale and scanty, and continued from two to 
three days. She never suffered pain at those periods. She has not menstruated 
since her marriage. 

Both before and subsequent to her marriage, she enjoyed good health ; and, 
although in the necessary duties of her vocation she has undergone an unusual 
degree of laborious exertion, still she ha< not had a day's illness. For two or three 
days before labour came on, she noticed a rather copious reddish discharge, that con- 
tinually drained from her ; but there was no pain. On the subsidence of this, about 
the 12th, slight pains in the back were felt, which went on till the night of the 14th, 
when they assumed the severe and urgent character which occasioned her to sum- 
mon her medical attendant at the time already stated. 

Having satisfied myself, at this second examination, that there really was no ori- 
fice into the uterus, and the pains continuing of a severe character — and the ex- 
istence of a living child being proved by the pulsations of the fcetal heart, which 
were distinctly audible, about twice as fast as the mother's pulse — I sought the 
advice of Dr. Ashwell. 

The Doctor lost little time in arriving; and having, by a careful investigation, 
positively confirmed the statement of the condition of parts already made, he deter- 



OF THE CERVIX AND OS UTERI. 327 

mined upon losing no more time in making- an artificial opening across the above- 
named spot, where the globular body seemed slightly thinner than elsewhere. The 
patient's pulse was about 120 to 130, very irritable; the pains violent; the skin ir- 
regularly hot and cold ; the features anxious ; the mind irritable ; general restlessness; 
the bowels had now been twice relieved by castor oil. Accordingly having placed 
her on her left side, the Doctor introduced his left forefinger as a director, upon which 
he passed up a curved, sharp-pointed bistoury, with his right hand ; and having punc- 
tured the spot already fixed upon, he incised forwards towards the bladder (which 
was empty), and backwards towards the rectum. At this last incision, a few drachms 
of dark blood flowed out. The liquor amnii of course escaped, and the head fell upon 
the artificial opening, which proved to be of the diameter of an inch and a half, or 
perhaps nearly two inches, and about a line in thickness. 

The Doctor did not incise laterally, lest he should wound any of the branches of 
the uterine arteries. At one o'clock a.m. of the 16th, he left the patient, in charge 
of Mr. Roe and myself. The pains abated for a brief space after the operation, the 
performance of which occasioned no suffering, so that she seemed not to be conscious 
of anything, beyond the inconvenience of manual interference. Pains, however, re- 
curred ; but little advance towards dilatation appeared to be made for some time, till 
about four a.m., when, under the influence of a severe pain, the edge of the orifice 
tore suddenly on the right side: and soon after, another rent took place, whilst my 
finger was at the part, backwards, towards the left sacro-iliac synchondrosis- She 
now became faint; the pulse was 140 or 150, feeble; the skin cold and clammy; and 
greatly exhausted. Ether, ammonia, brandy, and opium, were administered, and 
she rallied. After resting about two hours, the pains recurred gradually, and became 
as powerful as at any previous stage of the labour. 

The extent of the laceration on the right side could be reached by the finger; it 
had not extended to the vagina; that on the posterior part was beyond reach. No 
gush of blood attended these lacerations. The head became engaged in the pelvis, 
and the patient was delivered at 11 a.m. 

The latter pains were not powerful, and much stimulant was administered towards 
the close of the delivery. There was a more than usual degree of hemorrhage ; the 
infant (a male) was still-born, and with difficulty revived. 

The placenta was taken away in half an hour, and the uterus contracted well. 
Nothing further could now be detected on examination, but several ragged shreds 
about the orifice at the top of the vagina. 

The tongue was dry, and brown at the tip; the head ached ; the pulse was 110, 
jerking (doubtless referable, in some degree, to the stimulant). Towards the close 
of the labour, the bowels had afforded three copious motions. 

Liq. Opii sedativ. m. xl. statim. 

And to meet the expected reaction, 

Haust. Efferves. cum V. Ant. Tart, et Tinct. Hyoscyami aa 3ss. 4tis 

horis. 
Barley-water. — Quiet . 

5 p.m. Has been visited by Dr. Ashwell; pulse 104, no tenderness; tongue 
moister; bowels once more opened; has voided urine twice. Since the delivery 
there has been a copious draining (with some clots), which has trickled along the 
floor, having penetrated through the bed. This is principally urine; but there is 
evidently, also, a considerable quantity of blood. She has slept perhaps half an 
hour. Pergat. 

11 p.m. Has slept an hour, and is refreshed. Free from pain ; no sickness; pulse 
104. Has drank largely of barley-water. 

Liq. Opii sed. 3ss.; et pergat. 

Nov. 17, 10 a.m. Has slept about six hours. Pulse is only 84, soft; bowels open 
twice; urine free; tongue white, but moist; moderate perspiration; no tenderness. 
There has been but slight draining, tinged with blood. 

6 p.m. I was hastily summoned. She had three motions, in quick succession ; 
and, with the last there was much bearing down, followed by severe attacks of pain 
in the back and in front, with the expulsion of more clots. The pulse was 106, jerk- 



328 ORGANIC DISEASES 

ing; countenance rather frightened than anxious; there had been no rigour; but 
there was some pain on pressure over the womb. 

Pulv. Opii gr. i. statim. 

She was supplied with a bed-pan; with strict injunction to maintain the recum- 
bent posture under all circumstances. 

11 p.m. Has slept at least three hours. The pain has abated; there is almost 
none on pressure. Bowels quiet; pulse 96, softer. 

Liq. Opii^ss. statim ; et pergat. 

18. Mane. — Has slept nearly all night, and is quite free from pain or tenderness. 
Bowels open twice; but the pain prevents any comfort; pulse 90; tongue white, 
moist. 

Rep. Haust. Efferves. sine V. Ant. Tart, et T. Hyosc. 

Vespere.— Has been comfortable all day. Pulse about 90, soft ; tongue cleaner; 
no pain; bowels open once; urine free. 

Pergat ; et Opii gr. i. h. s. 

19. Slept well. Pulse 100, weak; bowels open twice; no pain. Discharge 
during the night was more profuse, with some clots of blood ; but the napkins have 
been put away. Asks for food. There is no milk, but the breasts are fillino-. 

Haust. Efferves. cum Tinct. Opii, m. v. 4tis horis. 
Liq. Opii sed. 5ss. h. s. 
Barley-water, and gruel. 

Nov. 20. This morning there is an abundant supply of milk in both breasts. The 
child sucks well from the right; but the left is enormously distended, and has no nip- 
ple. There is an extensive areola, with a slight central depression, and no milk has 
passed from it : as yet there is no hardness, but she suffers a good deal from disten- 
tion and pain. Pulse 110, jerking: tongue moist, slightly white ; bowels once open; 
no hardness, on pressure, over the uterus. There is" a copious, offensive discharge; 
but I have not been able to see a napkin. 

Omit. Medicamenta. — Low diet. Breast-pump. 
Nov. 22. Mr. Roe used the pump yesterday, and after much perseverance, suc- 
ceeded in drawing forward a portion of the areola, and procured a large supply of 
milk: since then, the breast is comfortable and smaller, and the milk oozes from it 
spontaneously. Pulse 90; tongue clean; bowels open; sleeps well; no pain; is 
hungry. Discharge abundant, greenish, muco-purulent, and offensive. 

Improve the diet; and continue the remedies. 

24. Child cannot seize the right breast as it is small, but free from pain, and the 
milk spontaneously issues from it. Discharge less in other respects. Doing well. 

25. Is doing well, and may be pronounced convalescent. Enjoined to keep her 
bed yet for some days. 

Dec. 4. On calling to-day, I find her weak, hut well. Since the last report, she 
has had some severe pain and tenderness about the pubes ; for which Mr. Roe (who 
has been most assiduous in his attentions) applied a few leeches, and the pain 
quickly subsided. There is still a profuse, greenish discharge from the vagina. Is 
weak. ° 

Ordered a little Quinine. 

14. Went this morning, in company with my friend Mr. Gaselee, to institute an 
examination into the present state of parts. It was with difficulty that even a manual 
examination was permitted. 

A day or two after the last-reported visit, the discharge assumed a reddish charac- 
ter, and so continued between three and four days: it commenced, continued, and 
ceased, like the catarnenial secretion, and was attended by no increase of symptoms. 
She is now nearly free from discharge; and though weak, is at the tub washing. 

The following is the result of a careful investigation: The vagina is short; its 
extremity, and every part o( it, can be readily reached by the forefinger; it presents 
no other peculiarity. 



OF THE CERVIX AND OS UTERI. 329 

There is no cervix uteri. The uterus seems reduced nearly to a normal unim- 
pregnated size. At the extremity of the vagina, there is a puckered, irregular ori- 
fice, into which the tip of the finger can enter : it is soft, with smooth and thick 
edges, not perfectly circular in consequence of certain indentations, as if from the 
drawing together of several small rents. 

It might be compared to the base of an apple ; whilst this part of a normal uterus 
would better resemble the apex of a pear. 

Radiating from this central aperture can be distinctly felt three ridovs, like line* of 
adhesion; one passing forwards, towards the right ilio-pubic jnnction,°traceable nearly 
to the reflexion of the vagina ; one opposite to this, backwards, towards the left sacro- 
iliac synchondrosis, whose extremity is lost in the reflexion of the vaojna ; and the 
third, of short extent, about one-third of an inch long, passing backwards and to the 
right. 1 nese > were distinctly ascertained, by both Mr. Gaselee and myself, to centre 
in, or radiate from, the aperture above named. 

This case is singular, especially when it is remembered, that the 
late Mr. Tweedie, Mr. Armstrong of Gravesend, and Dr. Lever have, 
in Mrs. P.'s three succeeding labours, been compelled to resort to in- 
cision. After every operation, her recovery was quick and quite 
I am not aware of any case having been recorded, where in 
four labours it was necessary to divide the lower part of the womb by 
the knife, to make a way for the child. After what has been advanced, 
there can be no hesitation about the treatment proper to be employed. 
The safety of incision consists in its prevention of unlimited and ex- 
tensive laceration. So long as division by the knife, and the subse- 
quent tearing of parts, is confined to the os and cervix, and does not 
extend beyond the reflexion of the mucous surface of the vagina over 
these parts, recovery is almost certain ; whereas, if the parts be left to 
rupture of themselves, the body and fundus of the uterus, and their pe- 
ritoneal investment, are pretty sure to be implicated : the result will 
then most probably be fatal. 



CHAPTER V. 

ORGANIC DISEASES OF THE MUCOUS MEMBRANE OF THE CAVITY 

OF THE UTERUS. 

The diseases of the cavity of the uterus, as polypi, sub-mucous tu- 
mours, malignant growths and ulcerations, physometra, hydrometra, 
moles, and hydatids, are difficult of diagnosis, being, till they are fully 
established, concealed from examination, while their accompanying dis- 
charges, whether of water, mucus, or blood, have frequently, prior to 
their discovery, fearfully injured the health. They are not equally 
alarming; a chronic catarrh of the lining membrane of the womb may 
be incurable, and the cause of sterility ; but it is far less dangerous than 
a fungoid tumour. 

Nor must it be forgotten, that in health, the mucous tissue of the 
uterus performs a variety of functions, secreting the catamenia, the de- 
cidua, and the lubricating mucus. Improved pathological researches, 
aided by the speculum and the finger, may often enable us to declare 
what a disease is not, thus lessening our doubt and uncertainty ; al- 
though for some further time we may not venture to declare its true 
character. There are no affections about which our suspense will be 
more painful. It is unnecessary, therefore, to urge the absolute neces- 
sity for unceasing and vigilant watchfulness, that every symptom may 
be met at the earliest moment, and as far as possible controlled. 



POLYPUS OF THE UTERUS. 

Definition. — A firm and insensible tumour, usually round and smooth, 
and growing by a stalk either from the mucous lining of the uterus, or the 
structure beneath ; its chief symptom being hemorrhage. It commences in 
the cavity of the womb, in the channel of the cervix, or from the os. It 
is often of fibrous textile, not malignant, and rarely ulcerates. It is 
covered by mucous membrane, and sometimes by an adventitious coat, the 
product of inflammation. There is little pain, menstruation is excessive, 
and conception may occur. 

* 

History and Symptoms. — Polypus of the uterus is not an uncommon 
disease, but certainly much more rare than cancer. Many months 
elapse, even in hospital practice, without the occurrence of one case of 
polypus : while it is unusual for a week to pass, without an out or in- 



ORGANIC DISEASES OF THE MUCOUS MEMBRANE, ETC. 331 

patient presenting a new example of carcinoma. There is no malady 
more certainly curable than polypus, although many patients may have 
died from its accompanying bleedings, without its existence ever having 
been suspected, much less ascertained. The necessity for vaginal ex- 
amination, where profuse uterine bleedings resist the remedies employed 
for their suppression, cannot be too strongly urged. In the hemor- 
rhages of polypus, astringents are useless— the only effectual remedy is 
removal. 

Pain can scarcely be said to be a symptom, and the first suspicion of 
the disease is excessive menstruation, or bleeding occurring in the cata- 
menial intervals. Although the evacuation of the bladder or intestines 
is seldom prevented, it is not impossible that a large polypus, by pres- 
sure on the urethra or rectum, or both, may obstruct their functions. 
Hence, if the patient be strong, the loss of blood seldom attracts notice, 
till some of its injurious effects begin to be realized. When the diges- 
tion becomes impaired and there is leucorrhcea, deadly sallowness, dif- 
ficult respiration, and other evils,— then anxiety begins, and it is not 
long till a reluctant permission is granted to examine the state of the 
womb. 

There is considerable variety in the size of polypi. I have 
known one not larger than a garden bean, give rise to frequent and 
alarming hemorrhages; and I lately removed a polypus by excision, 
larger than a Seville orange, which, from its commencement, had scarce- 
ly bled at all, but which ultimately produced irritation by its pressure 
on the neck of the bladder, and great exhaustion by constant and large 
secretions of pus. Few diseases are more quickly and accurately dis- 
tinguished when the growth has descended into the vagina, or even 
when still in the uterine cavity, if the os be sufficiently open to allow its 
bulbous portion to be touched. Under such circumstances, the finger 
may be passed round and between the tumour and the walls of the uterus ; 
the diagnosis being rendered more certain by the insensibility of the 
foreign body. 

The protracted inclusion of a polypus within the uterine cavity, is 
perplexing and dangerous. A small one, especially if it be soft and vas- 
cular, may give rise to alarming and even fatal losses of blood ; while, 
as the body of the womb is scarcely at all enlarged, and the os closed' 
we can only conjecture that such a disease may exist. 

Such instances have occurred in my practice, and a hard polypus of 
moderate size, now in Guy's Museum", removed when it had very par- 
tially descended through the cervix, fully attests the truth of the pre- 
ceding observations. This polypus grew so slowly, probably because 
the hemorrhages had been frequent and excessive, that three years 
elapsed prior to its coming within the reach of the finger. Durino- this 
period, the patient had been repeatedly seen by eminent obstetric ^phy- 
sicians, who in vain attempted to restrain the bleedings. At first, as 
she believed it to be entirely useless, I was not permitted to make an 
examination; but on my assuring her, that although the growth had not 
yet descended into the vagina, it might speedily do so, she consented; 
and I had then the opportunity of touching a small, hard, and insensi- 
ble tumour, just emerging from the os. the bleeding which followed 



332 ORGANIC DISEASES OF THE MUCOUS MEMBRANE 

alarmed me so much, that, before leaving the house, I attempted its 
removal. Excision was out of the question, and with a very long in- 
strument, I made two unsuccessful efforts before I could apply the 
ligature. When completed, the canula? were some way within the 
channel of the cervix. It was an anxious case, for there were several 
bleedings within the first two days, and from one of them it did not 
seem for some hours that she would have rallied. During the twelve 
days the ligature was applied, the patient was never quite free from 
uterine pain. Often I had to loosen the whip-cord, to foment the abdo- 
men with hot gin and laudanum, and twice a-day to give an opiate. 
At length, however, to my great gratification, both the instrument and 
the polypus came away. ' The swollen legs and feet, the deadly pale- 
ness of the skin, and the universal anaemia gradually vanished, and the 
patient is now, after a lapse of several years, in confirmed health. 

There can be no doubt, that women have died from hemorrhage, or 
the diseases resulting from the loss of blood (vide Case 63), where a 
polypus had really descended into the vagina, which might have been 
early and easily removed; and many have been lost from similar bleed- 
ing, where the growth was shut up in the uterine cavity, and beyond 
the reach of surgical assistance. 

Dr. Gooch has pointed attention to the fact, that polypi grow from 
different parts of the womb, from the fundus, from the inner surface of 
the cervix, but least frequently from the rim of the os uteri. 

I am not aware that the part from which polypus grows is not all- 
important in reference to the operation ; although it is thought that po- 
lypi attached to the cervix have a less tendency to hemorrhage than 
those growing either from the cavity or from the os. If the ligature be 
used, it must entirely include the peduncle, regardless of the spot whence 
it grows, and if the knife be employed, the excision of the same part 
must be complete. 

When a polypus grows within the uterus to any size, it dilates its 
cavity as in pregnancy ; but here the similarity ceases. For, even be- 
fore it descends, the os will not be sealed as after conception, but some- 
what more than usually open; and when the polypus is emerging from 
the uterus, the lips of the os will be thinned, and closely applied 
around the protruding body ; exceedingly unlike the uterine aperture 
in the later months. 

It is rare to find more than one polypus, and I have scarcely seen 
an example either of renewed growth after removal, or of polypus of 
the cavity, coexisting with one commencing in the circumference of 
the os. It is less rare to find two bulbs shooting from one stem ; and 
in Case 76 it will be seen, in a polypus of doubtful character growing 
from the os uteri, that I was compelled to tie the pedicle twice. 

Single women, and several of my patients have belonged to this class, 
are probably as subject to the malady as the married, nor is any tempe- 
rament exempted. 

Polypi commencing from the lip of the os are not always distinctly 
pedunculated, nor do they invariably assume the bulbous form. In a 
case lately under my care, I was several times foiled in an attempt to 
apply the ligature, owing to the lower part of the polypus being of 



OF THE CAVITY OF THE UTERUS. 333 

pointed form, while its base was exceedingly broad ; eventually I re- 
moved it by the knife. 

The irregularity of menstruation, nausea, and languor, the tension 
and dragging sensation, occasionally accompanying the disease, may 
for a time induce a suspicion of pregnancy ; and although it is rare, it 
is not impossible that conception may occur, if the growth, by its 
size, does not entirely close the os or the uterine extremities of the Fal- 
lopian tubes. After the removal of uterine polypi, pregnancy is rare, 
even where it had previously taken place, and in several cases which 
I have watched for years, conception has never recurred. 

It has been already remarked, that pain is seldom an attendant of 
polypus ; and yet where the uterus, distended by the growth, is ex- 
cited to contraction, there is pain in the hypogastrium, loins, groins, 
and thighs ; and in its efforts to push the tumour into the vagina, the 
womb is occasionally carried down towards the os externum. Hence, 
if the organization of the cervix be unusually firm, these expulsive 
contractions will be frequently and painfully repeated ; and the polypus 
may acquire considerable magnitude before its complete extrusion from 
the uterine cavity. 

In a case lately under my care, there was great suffering attendant 
on this process, and the ergot was beneficially given. For several 
weeks afterwards, from the greater size and dilatability of the vagina, 
there was neither pain nor bleeding ; but the peduncle grew, and the 
os and cervix tightly contracting on it, the superficial vessels were 
tied as by a ligature, and rupturing, hemorrhages frequently occurred, 
rendering removal absolutely necessary. 

In some instances mentioned by Dr. Campbell, the os tineas, by 
firmly grasping the peduncle, has entirely suspended the circulation in 
the tumour, and thus effected its detachment. Such an example has 
not come under my observation. 

Some polypi grow and distend the vagina to an enormous degree, 
without the occurrence of pressure ; but it is far more common that 
impeded and painful marital intercourse, mucous, sanguineous, and 
occasionally purulent discharges, admonish the patient that there is 
disease. 

The neglect of vaginal examination is never more conspicuously in- 
jurious than in polypus. I have seen patients, both in hospital and 
private practice, all but dead from its attendant bleedings, where not a 
single examination had been made. 

It must not be supposed, either, that uterine polypi are always of 
fibrous texture, or that they are always accompanied by frequent and 
large hemorrhages. Sometimes they are soft and cellular, having ca- 
vities filled with grumous blood, and neither externally nor within, can 
they be compared to fibrous growths. They may also be rough, gran- 
ulated, and firm on the surface ; while other portions are almost fun- 
goid. From these there is generally much bleeding. 

There is great variation in their size. Some are very small, and yet 
bleed profusely ; while the large polypi, having been much pressed 
upon and condensed in their structure, bleed but little. Still, in these 
22 



334 ORGANIC DISEx\SES OF THE MUCOUS MEMBRANE 

examples, the sufferer is much weakened by the constant leucorrhceal 
and purulent discharges. 

Thus from the great diversities in the size and discharges, whether 
of blood, mucus, or pus, and from the strength or weakness of the 
patient, there will be a marked difference in the effects. In some in- 
stances, the evils of the disease are so quickly realized, that there 
should be no delay in making an examination, which will at once lead 
to its discovery ; and if the polypus be still shut up in the uterine ca- 
vity, the slight benefit derived from styptic remedies, and the size ot 
the uterus and the altered state of the os, will lead to a suspicion at 
least of the real nature of the disease. 

If a polypus be suspected , and not found, the bleedings still continuing, 
the vaginal examination should from time to time be repeated On one 
occasion, a large double-bladed speculum so far opened the lips of the 
os as to bring into view a portion of the body of a polypus still shut up 
in the uterine cavity. There is no disease more likely to be regarded 
as cancerous, especially where the hemorrhages are frequent and pro- 
fuse, till examination has afforded the opportunity of determining its 
real nature. A blanched and cadaverous surface, impaired appetite, 
diarrhoea, oedema, tympanites, and emaciation, are almost sure to occur 
(vide Cases). Nor is it at all uncommon, where the blood comes away 
in clots, forming more or less accurate moulds of the polypus itself, 
that it may, from long retention in the vagina, become partially decom- 
posed and emit a fetid odour, thus confirming the erroneous diagnosis. 
Menstruation is often profuse and frequent, although I have known 
cases where its regularity was scarcely disturbed, and one or two m 
which the discharge was not in excess. 

Vomiting, dependent principally on the loss of blood, aided by the 
expulsive efforts of the uterus, and the dragging down of the tumour 
itself, is a constant accompaniment of advanced polypus. 

In some instances, noticed by various authors, there are regular 
bearing-down efforts, effecting the detrusion of the growth. In one 
such, occurring at Guy's, the stalk was broken, and the polypus came 
away. I have never known a new polypus grow from the portion ot 
peduncle left behind. 

Already, in Chapter III., page 234, " labour complicated with tu- 
mour" is fully discussed ; but it may be proper to remark here, that a 
large polypus may present so serious an obstacle to delivery, as to re- 
quire instant removal, the operation being most safely done by apply- 
ing, first, a ligature on the peduncle if within reach, and immediately 
afterwards cutting away the larger portion by a bistoury ; or if the 
noosing cannot be accomplished, the solid mass, resisting the passage 
of the head, must still be removed; the dangers of hemorrhage after 
such an operation being far less, than either delayed delivery or the 
consequences of protracted and severe pressure on the polypus and 
surrounding parts. Dr. Gooch mentions two cases. In one, where 
the polypus grew from the neck and lip of the uterus, it was discovered 
in the fifth month of pregnancy ; and, being removed by ligature, the 
pregnancy went on to the ninth month, and the patient was safely de- 
Jivered. In the other, the tumour was not discovered till the com- 



OF THE CAVITY OF THE UTERUS. 335 

menceraent of labour, and occasioned the death of the patient, a few 
hours after delivery. 

Mr. Borrett, an able surgeon at Yarmouth, has published a case 
where he found, on his first examination, a large fleshy tumour within 
the vagina, which, by its attachment, concealed the posterior segment 
of the os uteri, while the anterior was easily felt. As the head did 
not descend, he introduced his hand, brought down the feet, and ex- 
tracted the child. Eight hours after delivery strong pains came on, 
as if there was another child ; but as the abdomen was flat, and the 
contracted uterus could be distinctly felt in the abdomen, Mr. Borrett 
was satisfied that the uterus was empty, and gave her an opiate. 
The pains continued, with violent expulsive efforts, all night, and on 
examination, a soft, round tumour, pressing against the outer orifice, 
was discovered. The next morning she had a languid pulse and a 
pallid countenance; a large fleshy livid tumour had been forced out of 
the vagina; and every pain brought it more and more in sight. The 
patient continued to suffer and to sink through the rest of the day, and 
in the evening she expired. On opening the body, the uterus was 
found contracted, but its mouth was dragged down as low as the ex- 
ternal orifice, by a tumour which grew from it by a thick stalk. It 
was attached to the posterior part of the orifice, and some way up the 
neck, was of a livid colour, and weighed three pounds fifteen ounces. 
There can be little doubt, after the post-mortem inspections detailed 
in the Cases appended to Chapter III., that in this case, if a ligature 
had been applied round the stalk of the tumour, and its body cut off 
just below, that recovery would have been the result. Instead of in- 
flammation in and about the uterus, Dr. Gooch remarks, that the uterus 
was contracted, but that the polypus was of livid colour, plainly show- 
ing that gangrene of the tumour had resulted from its contusion during 
labour, and confirming the views expressed at page 236, " that when 
death occurs in labours thus complicated, it is only slightly, if at all, 
referable to lesion of the uterus ; the symptoms during life, and the 
inspections after death, proving that the unfavourable termination is 
mainly referable to inflammation, softening, and unhealthy suppuration 
in the growths themselves." Dr. Francis Ramsbotham has published 
a case of polypus complicating labour, where the tumour was expelled 
between the thighs, and where, for reasons deemed by him and his 
father quite sufficient, the growth was not removed till four months 
after delivery. Dr. Davis, too, advises " to delay the operation of ex- 
tirpation till after delivery, when the polypus is of moderate size, and 
has a neck of unusual thickness." Such cases, and the practice incul- 
cated, must however be regarded as exceptions to the rule I have laid 
down. 

Metritis has been known to occur after delivery, where a polypus has 
been retained in the cavity of the womb ; and in a case where I was 
consulted by Mr. Hammond of Edmonton, a tumour, the size of a large 
orange, imbedded in the posterior wall of the uterus, entirely prevented 
its natural contraction after labour. Death occurred at the end of a fort- 
night from inflammation and gangrene of this morbid growth. 

It is said that polypi by their weight, but especially by their sudden 



336 ORGANIC DISEASES OF THE MUCOUS MEMBRANE 

escape from the uterine cavity, may produce inversion of the organ. It 
is difficult to suppose this, if the uterus be unimpregnated ; although 
such an accident is vouched for on the most respectable authority. 
After labour, it is easy to understand how such an occurrence may take 

place. . 

Causes.— A variety of opinions have been entertained as to the cause 
of uterine" polypi: but as yet nothing absolutely certain has been estab- 
lished. It is most probable that they owe their origin to morbid change 
in the growth of the uterine mucous membrane, the result of irritation, 
or of slight inflammatory action. t 

They are said to occur most commonly in persons of lymphatic tem- 
perament, who reside in low and damp situations ; by some it is sup- 
posed, that their growth is attributable to the organization of a clot of 
fibrin retained in the uterus after hemorrhage. 

The diagnosis is not often difficult. A firm, insensible, and bulbous 
growth, having a distinct peduncle, embraced by the cervix uteri, and 
traceable into the cavity of the organ, cannot be a perplexing affection. 
For inverted uterus it can hardly be mistaken. Even if the growth 
has remained in the vagina, or in the cavity of the womb, during the 
whole of pregnancy, and has, after labour, either by its own weight or 
by uterine action, been pushed beyond the os externum, thus inverting 
the uterus and vagina, there may be difficulty in replacing the parts ; 
but there can scarcely be an error of diagnosis, as the very spot from 
which the polypus has grown would then be clearly seen, and the dis- 
tinction between the natural and diseased structure easily made. In 
every other case, the unchanged position and depth of the vagina, the 
presence of the os uteri in its natural site, and the generally smooth sur- 
face and the insensibility of polypus, would be sufficient guides. 

From scirrhous or hard tumour, by the absence of pain, induration 
about the cervix, and by the existence of a pedicle. 

From cauliflower excrescence, by its smoother, not granulated surface, 
its greater density, its capability to bear handling without hemorrhage, 
and its pedicle. Nor must it be supposed, in all cases where the sur- 
face is rough and uneven ; where blood follows an examination ; where 
there is pain and watery discharge, which may be only mucus, thinner 
than usual and colourless ; and where there is occasional fcetor about 
the discharge,— that the disease is necessarily malignant, or that the liga- 
ture may not be beneficially applied ; often, as has been observed at 
page 295, whatever may be the final result, there ought to be no hesi- 
tation about removing the diseased mass, where it can be done ; for it is 
impossible to tell infallibly by touch, whether the growth is so malignant 
that it will grow again, or how many years may be added to life by a 
timely operation. 

Prognosis. — So long as a polypus continues attached to the uterus, 
there must be danger. Sudden and large hemorrhage, or less but fre- 
quent bleedings, may exhaust and destroy the patient, or more proba- 
bly, dropsy of some of the great cavities will occur, and death be 
thus more gradually induced. Prolapse and inversion of the uterus, 
and the dangers attendant on labour, complicated with polypus, have 
been already pointed out. If, however, the disease be ascertained and 



OF THE CAVITY OF THE UTERUS. 337 

removed before the constitution is seriously injured, and if there be no 
diffuse induration of the uterus or disease of the lungs, a recovery may 
generally be predicted. 

Pathology. — There are few diseases which have excited more contro- 
versy than polypus uteri ; it being a generic name for a class of growths, 
springing from different parts of the uterus, and which, while they pos- 
sess one attribute in common, viz., that of spontaneous hemorrhage, 
differ materially in form, structure, density, and position. Thus, while 
some polypi, shut up in the uterine cavity, give rise to formidable and 
spmetimes fatal bleeding; others, which quickly pass through the ute- 
rine orifice, filling more or less the vagina, and occasionally appearing 
as pendulous tumours between the thighs, bleed but slightly. 

For practical purposes, it would be sufficient to divide these growths 
into the hard and soft polypi; but our improved pathology demands 
greater precision. The most common of all is the fibrous polypus, and 
it certainly far exceeds in frequency any other kind. 

Of soft polypi there is a variety, and their different designations by 
authors prove that between them there must be considerable pathologi- 
cal distinction. Thus the terms glandular, vesicular, mucous, and cel- 
lular, are but so many attempts to characterize a polypus softer, slimy, 
and more vascular than the fibrous species. There is also a peculiar 
polypoid growth, originating from disease of the glandulae nabothi of 
the cervix, which is pediculated, of moderate size, lobulated in form, 
and somewhat resembling nasal polypi. This is generally swollen, 
and filled with a viscous fluid; but polypi are not always round and pe- 
diculated, being sometimes cylindrical, and without any separation into 
stem and bulb. Lisfranc, following M. Malgaigne, enumerates five 
varieties; — The vascular, the cellulo -vascular, that consisting of hyper- 
trophy of the tissue of the uterus, the moliform, and the fibrous. 

The fibrous polypi vary considerably in several important particulars. 
Some are hard and tuberose; and these, when complicated with fibrous 
growths in other parts of the uterus, may be regarded as the same dis- 
ease, suspended from larger masses by the formation of a pedicle, and 
by descent through the os into the vagina. In such cases, bleeding, 
leucorrhoeal, and especially purulent discharges, and more rarely ulce- 
ration or breaking down of the separated portion will occur, and its re- 
moval by the knife or ligature is called for. Not unfrequently the 
fibrous polypus is fleshy and red, resembling the larger muscles; or, it 
may be harder and firmer, of a pale yellow, gray, or even white colour, 
and but slightly vascular. I have seen this species of 'fibro- cartilaginous 
hardness, but never, as Lisfranc mentions, either partially or entirely os- 
sified. Fibrous polypi differ much in their density ; sometimes they 
are of soft consistence, or partially hollow, containing distinct blood- 
vessels, or cysts filled with grumous blood, or as in one or two instances, 
gelatinous matter and hair, or fat with hair. Their external covering 
is generally derived from the mucous membrane of the uterine cavity ; 
and if their base, instead of being extensive and hard, is superficial, and 
immediately underneath the lining membrane, they quickly become 
pediculated, and from a very early period of their existence are pen- 
dulous. Polypi are devoid of nerves, and are therefore insensible. Oc- 



338 ORGANIC DISEASES OF THE MUCOUS MEMBRANE 

casionally, however, it is probable, that portions of the uterus grow into, 
and form a part of, the morbid structure itself: thus accounting for the 
continued, and sometimes severe pain produced by the first application 
and subsequent tightening of the ligature. It is not difficult to imagine, 
where a polypus has originated in the structure of the uterus, deeper 
than the mucous membrane lining its cavity, that for a time it will be 
imbedded amongst the uterine fibres ; but as it grows towards the cavity, 
these fibres, being distended and thinned, will eventually give way ; and 
the polypus wilf henceforth be covered almost entirely by mucous mem- 
brane, that portion of the polypus only nearest to the uterus being in- 
vested by the proper tissue of the organ. Nor is it very uncommon for 
the greater part of a polypus to be covered with an adventitious coat, 
partially or completely organised, the product of repeated inflamma- 
tion. In this way the sensibility of some uterine polypi may be satis- 
factorily explained. In a polypus I lately removed by excision, an ad- 
ventitious layer, distinct from the smooth mucous covering, was easily 
peeled off the bulbous portion, but it scarcely extended to the stem. 
Lisfranc says, the envelope varies in thickness, but is generally loosely 
attached, excepting at the base of the tumour, occasionally so much so, 
that enucleation can be effected with facility. " The envelope," accord- 
ing to this author, " usually alone forms the peduncle of the tumour, 
and it is not unfrequently perforated or absorbed, so as to expose the 
polypus at one or several points; and in a few rare cases, M. Lisfranc 
has seen it completely removed almost to the point of attachment to the 



tumour. ' : 



[As Mr. Ash well has not entered into the mode of formation of ute- 
rine polypi, and as I have been convinced by repeated observations, 
that many, if not most of them, arise from a coagulum of blood depo- 
sited either in the uterine parietes or cavity, I havethought proper to 
call the attention of the profession to this mode of origin. 

A coagulurn is formed in consequence of some lesion in one of these 
situations, and becomes organised by the entrance of vessels into it. 
The irritation produced by its presence, determines afflux towards it, 
and it becomes the seat of deposits of fibrin — finally, it protrudes 
and gets an investment from the mucous lining of the neck of the 
uterus, or vagina, the vessels being principally developed in this co- 
vering. I have been able to witness this process in almost all its 
stages. — Am. Ed.] 

The source of the vascularity of the polypi has elicited great diver- 
sity of opinion; but it may now, I think, be regarded as a settled point, 
that they are supplied by blood-vessels of their own, communicating 
with those of the uterus. Dr. Oldham has recently investigated this 
matter, and he regards their vascularity as residing essentially in the 
investing or connecting portion of the proper tissue of the womb, 
the arteries being enlarged, but very insignificantly as compared with 
the veins. " The amount of blood-vessels," he says, "in the fibrous 
growth itself, varies with the compactness and density of its structure; 
qualities which are produced in part by its infiltration with calcareous 
grains. When the growth is of long standing, and very hard, the sup- 
ply of blood-vessels, as shown by injection, is very scanty ; but in more 
recently-developed tumours, large and numerous arteries are seen pro- 



OF THE CAVITY OF THE UTERUS. 339 

ceeding from the uterine tissue into their substance, running in their 
intersecting lines, and dividing freely in the fibrous tissue. What has 
struck me, however, as peculiar, is, that the veins, although closely col- 
lected around the growth, do not appear to enter it. I injected a spe- 
cimen a few months since, when the red fluid, w T hich had been thrown 
into the arteries, had penetrated the tumour freely, and the trunks sub- 
divided into very minute capillaries, running parallel with the clear 
unstriped elementary fibre of the growth ; the veins, which had been 
filled with a yellow fluid, were not made apparent in the fibrous tumour, 
although they were very well injected around it, and throughout the 
uterus, and very beautifully demonstrated the capillary rete on the ex- 
ternal serous surface of this organ. A polypus, then, of this kind, is 
composed of a fibrous growth, with more or less of uterine structure, 
covered by the mucous membrane of the womb. The anatomical 
elements of the fibrous growth are a clear unstriped fibre, closely 
packed, interspersed in some instances with crystalline calcareous 
grains (the existence of which has long been known as a chemical 
constituent of them), and minutely divided arteries. On this point I 
may incidentally notice, that their minute structure adds one more 
to several other considerations which might be cited, excluding the 
fibrous tumours of the uterus from the class of malignant diseases." 

I may say, that I have seldom tied a polypus where any bleeding 
occurred after the lapse of a few hours from the noosing ; and further, 
that in only two or three instances, after either tying or excision, has 
there been any alarming loss of blood. It is not easy to understand, 
if the bleeding did not arise from the polypus, how Dupuytren could 
be correct in asserting, that, after his many operations by excision, 
alarming hemorrhage scarcely ever occurred. Bleeding, after either 
ligature or excision, will probably depend on the condition of the ute- 
rine tissue surrounding the base of the polypus. If this and the struc- 
ture beneath are healthy, there will rarely be hemorrhage ; if, on the 
contrary, they are soft and highly vascular, bleeding may occur. 

These pediculated tumours may inflame, suppurate and ulcerate ; 
nor are these changes confined to the vascular covering, for abscesses 
have been found in their interior, by Dupuytren, Lisfranc, and others. 
I have often known inflammation produce adhesion between the sur- 
face of the polypus and the channel of the neck of the womb, thus 
increasing the necessity, if the ligature be employed for their removal, 
that it should not be applied so high as to endanger the inclusion of a 
portion of the proper tissue of the organ. In one case (No. 76), I en- 
tertained scarcely a doubt of malignant change, and I have known 
polypi become, before removal, soft, and apparently infiltrated with 
serum. M. Lisfranc says, he has repeatedly seen fibrous polypi under- 
go cancerous degeneration ! I append an account of a polypus inject- 
ed and examined by Mr. Sibson, now of the Nottingham Hospital, and 
myself.* 

* " When first received, the polypus was exceedingly soft and pulpy, from putre- 
faction. By means of a blow-pipe, vessels running to the surface were inflated ; but 
from the pulpiness of the mass, it was impossible to insert an injecting-pipe. Mer- 
cury was, however, thrown into the vessels; but when it had run a very short dis- 



340 ORGANIC DISEASES OF THE MUCOUS MEMBRANE 

Treatment.— There can be no doubt of the propriety of the removal 
of a polypus when within reach, as a spontaneous cure rarely ever 
occurs, and there are but few instances where the danger does not pro- 
gressively increase. I have twice known the peduncle so attenuated 
by the weight of the bulb, that it has broken prior to the operation. In 
one of the cases, I had prepared to tie the polypus, in the ward at the 
Hospital, but on introducing my finger, I found it detached, and brought 
it away. I have never met with an instance where spontaneous cure has 
arisen from strangulation of the pedicle, by the neck of the uterus ; but 
I have preserved the bulb of a polypus, which separated spontaneously 
from its root, apparently by ulcerated rupture at its base; the bulbous 
detached portion weighing several ounces. This polypus I had several 
times examined, and I should have removed it, had not this natural 
detachment occurred. A polypus may be shut up in the uterine cavity, 
its existence being presumed from the hemorrhages, or it may not have 
descended, or it may be too large to pass through the uterine orifice. 
Under such circumstances, we must endeavour to control the bleedings, 
to support the constitution, and hasten the descent of the morbid 
growth. The recumbent posture, quiet, the application of cold, and 
plugging the vagina with soft dry tow, are our resources. Iced water 
and digitalis, and nutritious, unstimulating diet, must be given ; but the 
most favourable result can only place the patient in a state of tempo- 
rary safety ; removal is truly the only alternative. M. Lisfranc says, he 
succeeded in breaking up two intra-uterine polypi, by what he terms 
(arachement) avulsion, they having previously become soft and pulpy. 
In one instance, while attempting to depress a polypus for the purpose 
of excising it, he heard a sound, as if something had given way, and 
he found the polypus completely detached.* 

The same surgeon dwells on "enucleation" as a frequent means of 
removal, both for polypi and fibrous tumours, whether situated com- 
pletely within the cavity of the uterus, or partially in the vagina (p. 137). 
In one case, he perceived that the envelope of a fibrous polypus, con- 

tance, a vessel into which it had entered, whose calihre it was distending, gave way ; 
and although its further escape was arrested by gentle pressure, the injection being 
continued, the mercury again burst forth at an adjoining part. 

" The polypus was now immersed in weak spirit for several days, and its consist- 
ence was thus rendered much firmer. Mercury was again thrown in, by the pres- 
sure of a few inches of its own column; and although a great quantity escaped by 
the vessels terminating on the surface, yet a considerable number were filled. 

"The growth was rendered transparent by drying, so that the injected vessels 
might be more easily distinguished. During the process, much of the mercury was 
necessarily driven out, through the numerous apertures on its surface. A section of 
the polypus was then made, that the comparative vascularity of its surface and sub- 
stance might be better observed. 

"The superficial vessels, which presented numerous anastomoses, varied in size, 
from a dimension little more than a hog's bristle to that of a crow-quill. They ran 
in various directions, some of them having a convoluted appearance. 

«' At the centre of the polypus there was a vessel, which originated in the pe- 
duncle, and ran in a straight direction for about an inch : when it had reached the 
bulb of the polypus, it became extremely tortuous in its course: it was about the 
size of a large crow-quill. There were several smaller vessels in the substance of 
the tumour." 

* Clinique Chirurgicale, Tome troisieme, Paris, 1843, p. 39. 



OF THE CAVITY OF THE UTERUS. 341 

sisting of a thin layer of the tissue of the uterus, was torn; he passed 
his index finger through the rent, and enucleated the tumour with the 
greatest facility. In another instance, enucleation was accomplished 
in a few seconds. In a third example, where a fibrous tumour, as large 
as the clenched hand, protruded into the vagina, its envelope was lace- 
rated with the finger nails, and the contained tumour at once turned out. 
From a perusal of M. Lisfranc's essay, it is quite clear, that polypi still 
within the uterine cavity are not beyond the reach of his knife. "We 
made an attempt," (pp. 242-8) he says, "to excise an intra-uterine 
polypus; but the peduncle could not be detected, and a portion of the 
tumour, estimated at about half its bulk, was cut away ; the part left 
behind, however, sloughed, and the patient perfectly recovered !" 
These, and other processes, are propounded by M. Lisfranc; but it is 
a matter for congratulation, that such things do not require to be done 
in England. 

Polypi may be removed by Ligature and by Excision. Torsion or 
twisting off has been practised occasionally, and Siebold has success- 
fully used the actual cautery. 

Of the last method I have no experience, and I can see no reason 
why it should be employed. Small and cellular polypi of loose texture, 
may be seized either with the finger and thumb, or with a pair of for- 
ceps, and twisted gently round till the stalk gives way: this will be 
done without any hemorrhage. If the pedicle be too thick and firm for 
torsion, it is better to resort to one of the other operations. 

Removal by Ligature. — In England the ligature has always had a de- 
cided preference, and no better proof of its safety and utility can be 
adduced, than the general success attending its application. If a poly- 
pus can be noosed beyond its most bulbous part, in nineteen out of 
every twenty cases, the hemorrhage will be restrained; and more con- 
clusive testimony can scarcely be adduced, than that which supports 
this statement. From the imminent danger of the disease — its bleed- 
ings — the patient is almost invariably and at once secured by the suc- 
cessful application of the ligature. There may be difficulties in fixing 
it, and no doubt death has occasionally followed its use. But excision 
cannot always be practised; and the cases where it is difficult to apply 
the noose, are the very examples in which we should be afraid or una- 
ble to excise. Where excessive pain, inflammation, gangrene, and 
death have occurred, the ligature must have been incautiously used, or 
too long continued; although even in these instances, the evils might 
have been averted by timely removal. Not so, however, with excision : 
how much blood may be lost in the division of the pedicle, or how 
great the difficulty of stopping the hemorrhage, can only be conjec- 
tured prior to the severing of the growth. The hazard must at all 
events be encountered. 

Though preferring the ligature as the safest and most universally ap- 
plicable practice, I fully admit the value of excision, and especially of 
excision below the ligature; but, notwithstanding this admission, I still 
concur in the opinion of Gooch, " that the cure of polypus of the uterus 
(by ligature) affords one of the most striking instances of the triumph 
of our art." 



342 ORGANIC DISEASES OF THE MUCOUS MEMBRANE 

The great mischief to be avoided is the inclusion of a portion of the 
os uteri within the loop of the ligature, which might produce all the 
evils pointed out.* But this error can scarcely be committed, where 
the polypus is fairly in the vagina, if the operator is content to noose it 
just above its bulbous portion. 

It is important that the bladder and rectum be emptied; and although 
usually the best position for performing the operation is on the left side, 
close to the edge of the bed, the size, and form, and exact site of the 
polypus may require that the patient should lie on her back. It is un- 
necessary to dwell either on the instruments for tying, or on the different 
ligatures which may be used. The double canula, invented by Niessen, 
and improved by Gooch, is certainly superior to all others. To this 
instrument Laundy has ingeniously appended a silver windlass, which 
renders it quite perfect. The tightening of the ligature, without the 
windlass, especially when the whip-cord, from having been soaked in 
the discharges, has become dry and stiff, is really difficult; nor is it 
possible to do it with accuracy. Too much may be done, and painfully, 
or the ligature may be loosened in the attempt, and thus fail of its great 
purpose — the interruptiou of the circulation of the polypus, and the con- 
sequent destruction of its vitality. But, where the windlass is used, 
the whip-cord may be exactly and easily tightened, without the least 
fear of slipping, by which accident the rounded points of the canulee 
might be driven into the vagina. 

Another point of consequence, especially where the stalk is thick and 
firm, is to have the connecting rod long enough to reach within a quarter 
of an inch of the extremities of the canulse. This rod binds the canulae 
together, after the polypus is noosed; and if, as in Dr. Gooch's instru- 
ment, it does not reach higher than within one or two inches from their 
extremities, it permits them, when the ligature is tightened, to separate 
too widely, and thus the whole of the stalk is not so tightly grasped, 
and a longer time will be required for cutting it through. 

It must not be supposed that it is an easy matter to noose every poly- 
pus. The ligature may slip; and it may sometimes be thought that it 
encircles the stem, when it has not passed round it. Any attempt to 
draw the ligature tight will prove the error; nor in difficult cases will it 
avail for any good purpose, to be in haste or forcibly to attempt the noos- 
ing. In this, as in every other operation having to be done out of sight, 
gentleness, patience, and tact alone can insure its safe completion* 
Often when I have been foiled, and the ligature has become moist and 
slippery, the substitution of a new piece of whip-cord has facilitated 
the tying; nor is change of position an unimportant expedient. The 
operator must not be deterred from proceeding by hemorrhage; this 
very bleeding justifies continued efforts. 

Silver wire has been recommended ; but Burns says it is apt to twist, 
or to form little spiral turns, which impede the operation, and may 
eventually cut through the tumour. Silk cord, strong thread, or whip- 

* M. Dupuytren is reported to have met with eight or ten fatal cases after the use 
of the ligature, all of winch presented the symptoms arising from absorption of pus 
into the system. 



OF THE CAVITY OF THE UTERUS. 343 

cord may be used ; to the latter I give the preference, and now inva- 
riably employ it. 

[The article called Sea-grass line, and sold at the fishing-tackle stores, 
is the strongest cord known, and the best for this purpose. — Am. Ed.] 

The following are Gooch's directions ; and as it is impossible to ex- 
press them more clearly, they will be given in his own words : — 

The instrument which I use for this purpose, and which in nume- 
rous cases has assisted me through the operation, consists of two silver 
tubes, each eight inches long, perfectly straight, separate from one ano- 
ther, and open at both ends. A long ligature, consisting of strong 
whip-cord, is to be passed up the one tube and down the other, and 
the two ends of the ligature hang out at the lower ends ; the tubes are 
now to be placed side by side, and, guided by the finger, are to be 
passed up the vagina, along the polypus, till their upper ends reach 
that part of the stalk round which the ligature is to be applied ; and 
now the tubes are to be separated, and, while one is fixed, the other is 
to be passed quite round the polypus, till it arrives again at its fellow 
tube, and touches it. It is obvious that a loop of the ligature will thus 
encircle the stalk. The two tubes are now to be joined so as to make 
them form one instrument ; for this purpose, two rings, joined by their 
edges, and just large enough to slip over the tubes, are to be passed up 
till they reach the upper ends of the tubes, which they bind together 
immovably. Two similar rings connected with the upper by a long 
rod, are slipped over the lower ends of the tubes, so as to bind them 
m like manner ; thus the tubes, which at the beginning of the operation 
were separate, are now fixed together as one instrument. By drawing 
the ends of the ligatures out at the lower external ends of the tubes, 
and then twisting and tying them on a part of the instrument which 
projects from the lower rings, the loop round the stalk is thereby tight- 
ened, and like a silk thread round a wart, causes it to die and fall off." 

The latter part of these injunctions will of course be unnecessary, 
where the double canula is fitted with a windlass. 

The frequency with which the ligature is to be tightened will in a 
great measure depend on the pain it may produce, and whether con- 
stitutional irritation and fever arise. If these do not occur, the ligature 
should be shortened by one or two turns of the wind lass every morning, 
or night and morning. The foetor of the discharge and its acrimony 
may be lessened, by squeezing once or twice daily into the vagina, a 
few ounces of warm milk and water, or camomile tea. An elastic bot- 
tle with an ivory tube, which is easily passed by the side of the canula, 
is the best injecting instrument. 

It may be necessary occasionally to empty the bladder by the cathe- 
ter, and mild aperients may also be required. Hot fomentations of gin 
and laudanum, or of poppy-water, or a linseed meal poultice, will soothe 
abdominal pain, if it be dependent only on irritation. But if the pulse 
be quick and hard, if there be much fever, and constant and severe ab- 
dominal pain, aggravated on pressure, the ligature must be removed. 
Its continued use may lead to fatal peritonitis. Often, however, by 
slackening the ligature, which is easily done where there is a windlass, 
and when the symptoms have somewhat subsided, a very gradual re- 



344 ORGANIC DISEASES OF THE MUCOUS MEMBRANE 

tightening will avail for the perfect strangulation and subsequent de- 
struction of the polypus. Unless the symptoms are threatening, we 
must not hastily give up the operation ; but there should be assiduous 
watchfulness. 

I have never met with polypi insensible to the influence of the liga- 
ture. Such cases have occurred ; and one is related by Mr. Porter of 
the Meath Hospital, where there was no progress from the application 
of the ligature (Query, was it sufficiently tightened), it was removed by 
the knife. 

[I once assisted my friend, Dr. Betton, of Germantown, in removing 
a polypus by the ligature, which was twice as large as the head of a 
child at term. It grew by a broad base from the fundus uteri. — It had 
been removed once before, but the whole tumour not being included 
in the ligature, it had returned rapidly. — Am. Ed.] 

Excision. — Many of the disadvantages attendant on the use of the 
ligature, are avoided when a polypus is excised. It is quickly done, 
and without pain or injury to the neighbouring structures. But is it 
quite certain that we can always guard against the risk of excessive 
or fatal hemorrhage ? That there are many polypi which may be so 
removed, does not admit of doubt. Dupuytren is said to have cut 
away two hundred polypi by the knife, and hemorrhage only occurred 
twice. Velpeau's experience is favourable to excision, and Sir Benja- 
min Brodie has been fortunate in similar operations. Many other names 
might be mentioned. I have also removed several polypi by excision. 
On one occasion the hemorrhage required the plug ; in the other cases 
little or no blood was lost. But, if the polypus be large and of hard 
structure ; if it be of the white kind, already mentioned as having 
scarcely any blood-vessels ; if there has been but slight hemorrhage 
during its growth ; and if there be no pulsation in the stalk — excision 
will be the preferable practice. Or, if the operator incline to be cau- 
tious, he may noose it first, and either immediately, or in a few hours 
afterwards, excise below the ligature. 

If the polypus be still partly within the uterus, and the hemorrhages 
are endangering life, the ligature may be employed ; but here it would 
be impossible, at least with safety, and without forcibly dragging down 
the uterus, to use the knife. 

Polypus, complicated with inversion of the uterus, either in the un- 
impregnated or puerperal states, will be discussed when treating of in- 
version of the womb. 

The mode of operating by excision is not difficult. 
The patient being placed either on the back or side, and close to the 
edge of the bed, the polypus may be seized by a pair of dressing for- 
ceps, or by the instrument of Museux, and drawn as far as possible, 
without violence, towards or beyond the external parts. It is then to 
be fixed by the operator, and divided just beyond its bulbous portion, 
or as far up the stalk as can be done with safety to the os or cervix 
uteri, either by the bistoury or the clip of the scissors. 

In cases where the growth is small and the vagina long, it is not pos- 
sible to draw it down to the external parts ; in such cases, either a 
curved knife, blunt, and rounded at the extremity of its blade, or a 
pair of blunt-pointed and curved scissors, guided by the finger of the 



OF THE CAVITY OF THE UTERUS. 345 

left hand, maybe carried up to the polypus, and thus cut it across. If, 
after the operation, there be bleeding, or a danger of it, the patient 
must not be left. A plug of dry tow, and an astringent injection of 
alum, may be used : and in cases of excessive bleeding, turpentine, 
caustic, or even the actual cautery may be necessary. 



Case 70. 

The following four Cases were reported and condensed by Mr. 
Henry Oldham. 

Elizabeth H , aged 44, was admitted into Mary's Ward, in April, 1833, under 

Dr. Ashvvell. She is an unmarried woman, and has usually enjoyed good health. 
This was interfered with three years ago, by a profuse flow of the catamenia ; suc- 
ceeded by such irregularities in ihe performance of the function, as to induce the 
persuasion that it was about to cease. \ 

These passive hemorrhages were sometimes very copious, and not unfrequently a 
pint has been expelled at one gush. The character of this discharge changed about 
two years since, and assumed the appearance of coffee-grounds ; becoming also more 
irregular in its recurrence, and very offensive. This last peculiarity, however, wa8 
not constant : in the absence of a red discharge, there was one of a mucous kind. 

She now complains of great lumbar pain, extending to the sacrum with rigors, on 
the accession and going ofFof the sanguineous discharge. There is no bearing down, 
nor pain on micturition; but she occasionally feels a mechanical obstacle to the free 
exit of the urine. She experiences a sensation of fulness about the vao-ina, and a 
distressing sense of weakness on making any exertion. Her countenance and crene- 
ral surface are exsanguine ; and though not absolutely emaciated, yet the flabby con- 
dition of her muscles indicates imperfect nutrition. The cerebral symptoms conse- 
quent on hemorrhage are present, and the legs and ankles are oedematous at nio-ht. 
Dr. Ashwell examined, and entered the following repurt : — 

"I find a polypus attached to the fundus, about the size of a hen's-egg. The 
finger easily encircles its peduncle within the cavity of the uterine neck, and it 
extends half-way down the vagina. Its structure is firm, and insensible to the 
scratch of a pin." 

She was ordered to take tonics, and to maintain the recumbent posture, and in a 
few days the polypus was noosed by ligature. The double canula was the instru- 
ment employed, furnished with a piece of whip-cord of suitable length and thickness. 
The patient was placed at the edge of the bed, in the usual obstetric position. The 
forefinger of the left hand was passed over the enlarged portion of the polypus within 
the vagina, resting a little below the cervix. The canula was thus directed to the 
spot, and one of the tubes was carried round the polypus ; and on regaining its fel- 
low, was adjusted within the receiving tubes. The ligature thus applied was 
tightened, and its free extremities twisted round the shoulders of the instrument. 
The patient did not complain of the slightest pain, but spoke of an obscure feeling of 
strangulation of the part. The ligature was daily tightened; and the vagina was 
occasionally washed out with warm water. The polypus was separated, and came 
away with the instrument on the eighth day after the operation, appearing much 
diminished in size. 

From the time the ligature was applied, there was no further discharge. The 
patient daily improved, and she was shortly presented, cured. 

Case 71. 

Jane J , aged 47, a single woman, of slim make, whose aspect and sunken 

features conveyed the external symptoms of malignant disease, was admitted into 
the Hospital, under Dr. Ashwell, in August, 1834. 



346 ORGANIC DISEASES OF THE MUCOUS MEMBRANE 

Her health has generally been feeble ; but, with the exception of several hysteri- 
cal symptoms, did not materially stirrer until three years since: at this time the 
catamenia, which had hitherto flowed naturally, became very profuse, lasting twelve 
or fourteen days, and attended by clots. A copious, purulent, and very feiid dis- 
charge succeeded this | assive hemorrhage, and alternated with the menstrual flow. 
With the exception of rather too profuse menstruation, she did not suffer from 
hemorrhage during the growth of the polypus; hut her present attenuated and very 
weakened state seems attributable to the purulent discharge, which continues un- 
abated. 

An examination was instituted by Dr. Ashwell, who reported: — 

»' I find the vagina completely filled up by an insensible pyriform body, which 
almost protrudes through the external labia. This growth is encircled by the os 
uteri; but the finger can pass between them, excepting at the posterior part of the 
interior of the cervix, where the polypus is attached ; and here the os is attenuated. " 

The bowels were regulated ; and sulphate of quinine, in the compound infusion of 
roses, was administered. On the 27th of August, the polypus was tied ; and when 
the ligature was tightened the patient did not complain of pain. In the evening, 
there was some abdominal tenderness, which probably arose from a distended blad- 
der. The catheter was passed, and an opiate administered. She experienced no 
further suffering: the ligature was tightened daily: and on the 5th of September, 
nine days from the operation, the polypus was cut through, but with some difficulty, 
owing to the smallness of the vagina, withdrawn. It is worthy of remark, that the 
discharge ceased after the polypus was tied, nor has it since recurred. Her general 
health rapidly improved, and she soon left the Hospital, cured. 



Case 72. 

Mary Anne W , aged 35, the mother of three children, but now a widow, has 

been suffering for the last two and a half years from uterine hemorrhage. This 
occurred, without any premonitory symptoms, in profusion ; but has since been 
diminished in quantity, but constant. She is now the subject of anaemia, the surface 
being uniformly blanched; and her general health has been daily declining. 

On examination, a polypus was discovered, just protruding through the os, insen- 
sible to pressure. It was probably attached to the body of the uterus, as the finger 
could be passed round the cervix. 

The loss of blood which this patient was daily sustaining, determined Dr. Ashwell 
to attempt to strangulate the polypus; but its very slight descent, and the unusual 
length of the vagina, frustrated the endeavour. On the evening of the same day 
flooding occurred ; the pulse was almost imperceptible at the wrist ; the pupils con- 
tracted ; and she appeared comatose. Active measures were employed to arrest the 
hemorrhage, which was accomplished by plugging the vagina. She gradually re- 
covered from this attack; and a longer instrument having been procured, the polypus 
was tied on the 4th of October. 

No further hemorrhage occurred, nor did the patient experience any pain ; and 
on the eighth (four days after the operation) the polypus was cut through. This 
woman regained her former health and spirits, and left the Hospital quite well. 



Case 73. 

Georgiana W , aged 34, was admitted October 23, 1834. She is a delicate 

strumous woman, and was delivered of a six-months' child ten months ago. For the 
last two years she has been supposed to labour under menorrhagia, and every variety 
of treatment has been employed without success. To arrest the hemorrhage, she 
attended as an out-patient at the Hospital, and the secale cornutum was administered ; 
but as the discharge continued, she was examined. A large polypoid growth 
was discovered, partly protruding into the vagina, but encircled by the os and 
cervix, the former of which was exceedingly attenuated. Scruple doses, repeated 
three times, of the secale cornutum, were administered, with the hope of procuring 
a further protrusion of the polypus, and its release from the embrace of the os and 
cervix. This had the desired effect, and Dr Ashwell tied it without difficulty. The 



OF THE CAVITY OF THE UTERUS. 347 

catheter was passed for two days after the operation, which was not accompanied or 
succeeded by pain. Warm water injpctions were used during the separation of the 
polypus, which was accomplished in eight days' time. This patient recovered with- 
out a bad symptom. 

Observations. — The above four cases are not devoid of interest. In 
all of them an examination had been neglected till the symptoms were 
so urgent as to forbid further delay ; so that unnecessary loss of blood, 
and to an injurious and alarming extent, was the result of this great 
practical error. Jn one instance there was no hemorrhage, but a con- 
stant secretion of pus ; nor does it appear that such a process was bet- 
ter supported than loss of blood ; for the patient, in Case 71, was more 
anapmiated, and had more of the malignant aspect, than any of the other 
patients. Excepting (in No. 72) where the polypus had only partially 
emerged from the uterine cavity, there was no difficulty in the opera- 
tion ; and even there, a longer instrument rendered the noosing of the 
growth easy and safe. In none of the patients were there any after- 
symptoms, inducing solicitude or risk. In all of them the hemorrhage 
ceased immediately on tightening the ligature; nor did it again occur, 
— a tolerably good proof that the hemorrhage, in these instances at 
least, arose from the growth, and not from the uterus. 



Case 74. 

POLYPUS, COMPLICATED WITH SCIRRHUS OF THE UTERUS. 

For the dates and other particulars of this case, I am indebted to 
Mr. Thomas Hawkins of the Kent road, who attended with me. 

Mrs. B , set. 49, of wan and emaciated aspect, has been married twenty-five 

years, and is the mother of seven children. She has often miscarried, and since the 
last abortion, seven years ago, having previously enjoyed good health, has suffered 
from bearing down of the uterus, slight difficulty in evacuating the rectum and blad- 
der, and constant mucous, and occasionally sanguineous discharges. Soon after- 
wards the difficulty of micturition increased, and the retention was so complete, 
that her medical attendant was compelled for some weeks to draw off the urine by 
the catheter. 

In July, 1835, I first saw Mrs. B„ and found a firm and smooth polypus occupying 
nearly the whole vagina, and growing by a very broad base from the lower part of 
the uterus, involving the posterior half of the channel of the cervix, insensible to 
the scratch of a pin, and conoidal in form, the apex of the cone being below, and the 
base above. The posterior lip of the os was obliterated, and the anterior was thin and 
expanded. The uterus itself was indurated, and so enlarged from scirrhus, as to 
fill the lower half of the abdomen. As the purulent discharge was constant, and her 
strength so much exhausted as to compel her to lie almost constantly in bed, 1 tried 
to apply the ligature, but after several attempts, being foiled by the size and, form 
of the tumour, I proposed excision. To this she would not then assent, and I was 
not again called to see Mrs. B., till March, 1841. 

The polypus now not only fills the vagina, but protrudes many inches beyond its 
orifice; it is dark-coloured, partially ulcerated, and sloughing. The patient is very 
weak and emaciated, the purulent discharge constant, and the smell exceedingly of- 
fensive. Since my last visit, there has not been any rapid growth of the tumour, no 
pain, except from pressure on surrounding parts,'and difficulty in evacuating the 
bladder and rectum, and but few large hemorrhages, these having been superseded 
by the increasing purulent discharge. The disease in the body of the uterus has 



348 ORGANIC DISEASES OF THE MUCOUS MEMBRANE 

not increased ; but the vagina is so entirely filled, that it is impossible to ascertain 
the condition of the os and cervix. Since the polypus has descended so low, and par- 
ticularly since its expulsion beyond the external parts, the abdominal distention is 
less • but since ulceration has commenced, her health has more rapidly failed. Lite 
pulse is quick and feeble, appetite nearly gone, and she has constant fever, with 
nightly exhaustion from want of sleep. 

On the 23d March, 1841, as she was exceedingly anxious to have it done, a liga- 
ture was tied round the growth, three inches within the vagina and the portion be- 
low, weiahincr more than eight, ounces, was removed by a bistoury. I here was 
neither pain nor bleeding, the cut surface presented a white, fibrous structure; 
there were rather numerous bloody points; but no cells or large vessels The mass 
thus removed was washed and carefully examined, but it was too soft and sloughy to 

permit accurate observation. , , . . ... ,. e tU a 

The lioature came away on the 31st of March, bringing with it a portion of the 
polypus, decomposed and offensive. An examination proved that the upper part ot 
The vaaina was still partially filled by a growth, firmly consolidated with the poste- 
rior lip°of the os; but her health was better, and some time afterwards 1 heard she 
could get out of bed, and to a certain extent, resume her usual occupations. 1 he 
uterine scirrhus, if advancing at all, does so very slowly. 

Case 75. 

reported by dr. joseph ridge. 

Hannah T , est. 49, a washerwoman, was admitted under Dr. Ashwell, into 

Petprsham Ward, September 24th, 1836, with a sallow countenance, congested 
cheeks, livid lips, and hurried respiration, and all the aspect of chronic viscera dis- 
ease She states that her life has been laborious, that she has borne seven children, 
has not indulged in spirituous liquors, and has enjoyed good health till within the last 
six years. During this period, especially since April, menstruation has been profuse, 
not infrequently passing into flooding. It is evident from examination by the steth- 
oscope, that there is extensive organic disease of the heart, and of the left lung, which 
is entirely irrespirable. There is nu lumbar or pelvic pain ; pulse 120, very small 
and feeble; there is slight anasarca of the lower limbs. 

September 25th. The countenance is increasingly turgid, and the dyspnoea greater. 
Percussion affords a very dull sound over the whole of the left lung, and auscultation 
reveals no respiratory murmur, but only a bronchial respiration, and bronchophony is 
distinct at the apex. The heart's impulse is diffused and somewhat tumultuous. A 
"bruit" is heard to the left of the sternum, just before the second sound. 

The face and limbs bear increasing signs of obstructed circulation and respiration ; 
complains of being uneasy all over, and says she has a flow from the vagina. Lx- 
amination detects a growth from the uterus, projecting into the vagina, circular and 
smooth, but softer than the majority of polypi. 

A few hours afterwards she died. 

Sectio Cadaveris.—\ pass over the examination of the heart and lungs with this 
observation, that their diseased state was precisely what might have been anticipated 
as the result of long-continued loss of blood. 

The uterus was elongated : when laid open, a polypus larger than a hen s-egg was 
seen to hang out of its cervix, the rim of the os being lost in the vagina, which was 
slightly distended for the accommodation of the tumour. The peduncle was short 
and thick, growing broadly from the posterior part of the uterine cavity, just above 
the cervix. The investing membrane of the polypus was of dark colour and 
greenish, and at one point slightly excoriated. The interior was white, and but 
moderately injected with blood-vessels; its texture was not very definite; there was 
some appearance of uterine fibre; and there were also numerous soft and whitish 
bodies, about the size of small peas, imbedded in coarse, loose, reticular tissue. 
The mass, when cut into, was flabby and very ! yielding, but not at all inclining to soft- 
ening or destruction. 



OF THE CAVITY OF THE UTERUS. 349 

Observations.— This case is narrated to show the extreme danger 
of neglecting examination. The polypus had probably been long°in 
the vagina ; and as the worst symptoms were of recent date, its re- 
moval six or eight months previously might have prevented both the 
pulmonary and cardiac disease. 



Case 76. 

REPORTED BY THE CLINICAL CLERK. 

!\Jary C, set. 30, was admitted under Dr. Ashwell's care, July 5th, 1838 She 
is of sallow complexion, although of healthy family, and has dark hair and gray 
eyes; has been married ten years, and is the mother of five children. 

A month after her last confinement, in 1837, she suffered pain durino- intercourse 
and had a constant punform discharge. These symptoms were followed^ prolapsus 
and hemorrhage, and, on the first flooding not less than three pints of blood came 
away in one or two minutes. From that period up to the present, July 5th, 1838, 
there has scarcely been a day without discharge more or less copious, either of fluid, 
or coagulated blood. 

An examination detects a tumour in the vagina, as large as an oranae,more or less 
round, quite insensible and attached to the posterior lip and side of the os, leavino- a 
passage into the uterus anteriorly. It was tied without difficulty on the 6th of July Ihe 
ligature coming away on the 19th, thirteen days after the operation. In a few weeks 
she left the hospital, the stalk of the polypus not having disappeared. There was 
occasionally slight hemorrhage, but her health had materially improved. 

October 19th, 1838— Mrs. C. has again become an in-patient. The bleedino-s 
have returned, and the growth is now so large, that pressure upon it, when she sfts 
down, is painful. There is a copious and offensive watery discharge, and a frequeit 
desire to pass urine, which is always done with burning pain. Diarrhoea has lately 
eomeon; the pulse is 84, and compressible ; the tongue clean, and there are occa- 
sional violent headaches. No appetite, much perspiration, and considerable ema- 
ciation. 

November 2d.— A ligature was applied to-day, and in the evening she complained 
of pain, the pulse rising to 120. On the 4th November the ligature was tightened 
and on the 5th ^t came away, during the evacuation of the bowels, with a portion of 
the growth. r 

From this penod to December 11th, her health was seriously impaired by frequent 
purulent and sanguineous discharges; and on examination the vao-ina was found to 
be nearly filled by a fungoid growth, so soft as not to permit of its being noosed 
btrong astringents were thrown into the canal, and tonics and good diet were freely 
exhibited. In January, being threatened with phthisis, she was made an out-patient ; 
strict injunctions being given for the observance of the recumbent posture, and the 
use of the astringent injections. In a few months she rallied ; the Growth slouched 
and in December, 1842, I had an opportunity of seeing her quite well. 

Remarks.— This is a deeply interesting case. Hardly a doubt was 
entertained of the malignancy of the growth, and when the threaten- 
ing of phthisis occurred, there seemed no chance of recovery, yet even 
here a cure took place almost independently of remedies, and durino- 
1841 she became the mother of a living child. 
23 



350 ORGANIC DISEASES OF THE MUCOUS MEMBRANE 



MALIGNANT GROWTHS AND ULCERATIONS OF THE UTERINE 

CAVITY. 

Malignant growths arising from the cavity of the womb are rare, 
if we except those arising during the progress of carcinoma. I have, 
however, seen two specimens of fungi in this situation, unconnected 
with cancer. In one, an out-patient at Guy's, which destroyed life by 
bleeding, the growth reached nearly to the cervix, being raised about 
a quarter of an inch above the surrounding tissue : but in most of these 
instances the productions were probably connected either with polypi 
moles, hydatids, or cancer. It seems hardly necessary to dwell at 
length on these affections, as the symptoms must be doubtful, so long 
as the growth is confined within the cavity, notwithstanding the aid to 
be derived from examination of the rectum and vagina. Still, if blood 
be lost frequently, and in large quantity, if there be burning or lanci- 
nating central pains, emaciation, and fetid and weakening discharges, 
the prognosis must be unfavourable. 

Although a fatal result may be long delayed, it is almost certain to 
occur. Singularly enough, however^ some of the dangerous diseases 
of the uterus, in which at first there seems only a very slight chance of 
protraction, pass into an inactive state, and under favourable circum- 
stances, allow an unlooked-for prolongation of life. 

The treatment can only be palliative. The strong alum hip-bath (a 
pound of the salt to a gallon of water)— care being taken that the fluid 
passes up the vagina — is one of the best remedies. Many other aux- 
iliary means may be tried ; and if the diseased mass, or a large portion 
of it, shall pass into the vagina, it may be removed by ligature, or by 
any more suitable method. 

SPONGOID TUMOUR, OR FUNGUS H^MATODES UTF,RI. 

Burns has adopted the former, and Dr. Francis Ramsbotham the latter 
designation. I have seen but one example of this very rare disease, 
and even here an examination after death was not permitted. The his- 
tory of such cases differs from cancer, the enlargement not commencing 
in the cervix, but in the body, and rapidly, as in the case I had 
under my care, affecting the entire structure. If examined by the rec- 
tum, the uterus much larger than natural, is felt to be lobulated and 
elastic, and without any induration. Its mischievous effects on the 
general health are early apparent ; the pulse being quickened, the 
strength rapidly failing, and the. stomach and other organs quickly 
giving way. The pain is said to be agonizingly severe, and occasionally 
lancinating; and, probably, even before ulceration is set up, there are 
profuse sanguineous discharges : in their intervals there is an almost 
constant escape of an offensive, dark-coloured, purulent fluid, which 
not unfrequently, by its acrimony, excoriates the pudendum. The pain 
increases as the disease advances, and the final termination is similar to 
carcinoma. In the case above alluded to, although there were many 



OF THE CAVITY OF THE UTERUS. 351 

symptoms resembling cancer, the larger size of the uterus, its rising 
above the pubis, and the freedom of the vagina and the rectum from 
induration, sufficiently established the diagnosis. The os was capacious 
enough to admit one or two fingers ; and ulceration had affected its 
posterior lip. As to treatment, it can only be palliative, and the obser- 
vations on this subject, appended to the chapter on cancer, are equally 
applicable here. 

ULCERATION OF THE MUCOUS LINING OF THE UTERUS. 

This is the least common disease to which the womb is liable : not 
that there is anything singular in partial ulceration of the cavity, and 
especially low down, or in the channel of the cervix ; but general ulce- 
ration of the membrane, with thinning of the walls and dilatation of the 
cavity resembling pregnancy, may certainly be regarded as a very 
unusual event. Such a case I have not seen. Dr. Francis Ramsbotham 
preserved a preparation of this disease, in which the organ acquired 
the size of a pregnancy of the fourth month, and where, being turned 
inside out, it was seen to be everywhere ulcerated. The parietes were 
not more than a quarter their natural thickness, and there was a ragged 
aperture at the fundus, large enough to admit three fingers. 

Dr. Ramsbotham, senior, and Dr. Gooch seem to be the only authors 
who have noticed this affection, and it is somewhat singular, that they 
both record the same case, having seen it together. The following is 
the history of its progress, and of the appearances observed on dissec- 
tion as published by the son of the former distinguished physician :— 
lhe lady, the mother of a family, considered herself between three 
and four months advanced in pregnancy ; but the abdomen was en- 
larged to a size equal to what it has usually acquired towards the close 
ot gestation. When my father first saw her, the uterus was distinctly 
perceptible above the pelvis, large, firm, resistant, and acutely painful 
throughout its whole extent, on pressure being applied. One portion of 
it, within the right ilium, was more tender than the rest. She had a 
dejected countenance, and was suffering under fever, with great irrita- 
bility of stomach, and excessive irritation over the whole surface of 
the skin. She had been the subject of a constant discharge from the 
vagina for the preceding five or six weeks, in greater or less quantity, 
sometimes perfectly sanguineous, at others more serous, but devoid of 
unpleasant odour. Her increase in size had been uniformly progressive 
though rapid. As in her last pregnancy a dropsical state of the ovum 
occurred, the inordinate enlargement of the uterus was now attributed 
to the same cause. She became worse, and Dr. Gooch saw her, in con- 
sultation with my father and her other professional advisers. On an ex- 
amination per vaginam being now made for the first time, doubts arose 
both in Dr. Gooch's and my father's mind, as to the correctness of her 
opinion that pregnancy had occurred. The cervix uteri was found 
elongated and thickened, the mouth soft, flaccid, and sufficiently open 
to admit the passage of the finger within it about half an inch, but no 
substance could be detected in the cavity. The treatment directed 
was merely palliative ; and as the bad symptoms became aggravated, 



352 ORGANIC DISEASES OF THE MUCOUS MEMBRANE 



» 



on another consultation, five days after the former, it was determined 
to introduce a catheter within the uterus, that the liquor amnii might be 
evacuated, provided it contained an ovum. The instrument passed high 
up without encountering any impediment or obstruction ; it could be 
"moved about, as if in vacuo?'' A few hours after this means had 
been adopted, periodical pains came on, with a little increase of uterine 
discharge : these ceased spontaneously, in a short time exhaustion super- 
vened, and the same day she died. 

"On inspecting the body after death, it was remarked that the 
abdomen was tumid, and soft under the hand, having lost its former 
firmness. The peritoneal cavity contained a quantity of offensive gas, 
which escaped on the parietes being divided. The uterus was as large 
as though six months of pregnancy had elapsed. Its external surface 
was preternaturally red ; it was flabby in texture, and, on squeezing it, 
some blood escaped through the vagina, mixed with puriform and serous 
fluid. The parietes were softened, and had much of the appearance of 
the gravid state. The cavity, which would easily have held the head 
of a child at birth, contained no foetus, nor any other substance that 
could be looked upon as the result of impregnation. The whole inter- 
nal membrane was destroyed by ulceration, and the surface was granu- 
lated. Adherent to the back part of the body was found a shreddy 
fibrinous mass, the size of a large egg, entangled among the irregula- 
rities of which were coagula and a quantity of bloody puriform matter. 
At different points near the cervix, the structure was eaten through 
nearly to the peritoneal covering. 

" With regard to the treatment of such a case, we know so little of 
its nature, that I can only recommend you to palliate whatever danger- 
ous symptoms may arise. If, indeed, we were quite sure the disease 
under our care was of this kind, astringent fluids, injected into the ute- 
rine cavity by a properly contrived syringe, might induce a more 
healthy action, and, perhaps in the early stage, be productive of essen- 
tial benefit." 



PHYSOMETRA, OR TYMPANITES UTERI. 

As the uterus is naturally shut up, and greatly increased in size, 
during pregnancy, so in its unimpregnated state, as the result of func- 
tional derangement or inflammation of the lining membrane, from death 
and decomposition of the ovum, from retention of a portion of pla- 
centa, which may become putrescent, or from accumulation of the cata- 
menial fluid, the cavity may be closed, and the entire viscus greatly 
enlarged. 

The contents of the womb, under such varying circumstances, must 
be different. Where, for instance, the solid parts of an embryo have 
been retained, consolidated by pressure and covered with layers of 
coagulable lymph, a firm mass will be formed, to which, when expelled, 
the name of mole is usually given. But w^here the menstrual fluid 
is not permitted to escape, however long it may be shut up, it still re- 
mains fluid ; and there will be no difficulty, when it has escaped, either 
spontaneously or by operation, to determine its true character. 



OF THE CAVITY OF THE UTERUS. 353 

The pathology of such diseased actions is soon understood ; but it is 
more perplexing to get at the precise cause of an idiopathic disten- 
tion of the uterus by gas, and of the process by which the os, in order 
to allow of its accumulation, becomes sealed. " There seems no reason 
for doubting that these events do occur, Frank, Astruc, and others 
having accurately recorded their histories. It is probably true, that few 
if any of these larger collections of gaseous fluid take place, independ- 
ently of pregnancy, parturition, or organic disease. We can suppose 
that air, being secreted by the extreme branches of the uterine vessels, 
may escape involuntarily, and not always silently ; but where it is re- 
tained, and the uterus becomes gradually distended, so as to produce 
a real tympanites, inflammation in and around the os must have taken 
place, or induration and contraction of the canal of the cervix from 
some more permanent cause. 

Mr. Hunter was interested about a case of this kind ; but he failed, 
on an examination after death, in discovering any disease either of the 
uterus or vagina. 

Many singular cases are mentioned by different authors. It is said 
that air has been known to accumulate in the uterine cavity after the 
death of the foetus, or between the amnion and chorion, the foetus be- 
ing alive ; and Baudelocque was present where the gaseous exhalation 
occurring after death, was sufficient to expel the foetus. 

Peter Frank, a name of high repute, relates an example, where after 
death the uterus was hard, enlarged, and elastic, and full of gas of a 
very fetid smell. There was also ulceration in the cavity, and the 
neck was indurated. In another case, the os was closed by a polypoid 
growth. By the same author it is stated, that in the wife of a German 
physician, the accumulation of gas was so great, that the womb reached 
from the pubis to the diaphragm. 

I have never seen a true case of tympanites— one where the air has 
been the product of morbid secretion from the uterine vessels, and 
where, from closure of the os, it has been allowed to collect for weeks 
or months in the uterine cavity, and has then, either spontaneously or 
by operation, been expelled; but I have several times been called on 
to cure explosions of gas from the vagina, which, forming in the ute- 
rus, escaped involuntarily, and with so much noise as to prevent the 
sufferer from venturing into society. In one patient, pregnancy always 
cured the disease ; and Gooch confirmed the uterine origin of the o- as 
in these slighter affections, by the fact, that in a patient of his, the in- 
stant pregnancy occurred the malady ceased, returning a few weeks 
after delivery. Idiopathic uterine tympanites is no doubt an exceed- 
ingly rare disease. Physometra, on the contrary, dependent on chemi- 
cal change in the secretions, although a rare, is a more common affec- 
tion. Thus the menstrual fluid, the vaginal and uterine mucus, coagula 
resulting from menorrhagia or dysmenorrhoea, the ichor of cancer, por- 
tions of placenta or of polypi, may, by their partial or entire decom- 
position, give rise to larger or smaller quantities of gas. A few months 
ago I had to remove a large mass of partially adherent placenta, which 
for three weeks subsequent to labour had caused frequent and larcre 
hemorrhages. On entering the uterine cavity, which was partially 



354 ORGANIC DISEASES OF THE MUCOUS MEMBRANE 

blocked up by a firm coagulum, Mr. Woolnough, a student of Guy's 
Hospital, and myself, were surprised by the escape of an immense 
quantity of fetid gas, doubtless the consequence of the putrefaction of 
the retained viseus. 

The diagnosis cannot be difficult, for although menstruation is sus- 
pended, and the abdomen becomes enlarged, and, according to Frank, 
milk is secreted, still there will be so much elasticity about the tumour, 
and such disproportionate increase at an early period of the supposed 
pregnancy, that doubt must arise. This doubt will soon become a cer- 
tainty as to the non-existence of gestation, by the partial or entire 
expulsion of the air, and by the consequent diminution of size. A fall 
or blow, even the sudden bending forward of the body, sneezing, 
coughing, or vomiting, have induced the discharge of the gas, suc- 
ceeded by the escape of a more or less sanguineous fluid. 

Treatment. — In cases where such accidental circumstances have not 
led to the cure of the disease, or where the gaseous accumulation 
causes severe and extensive pain, nausea and vomiting, or difficult 
breathing, the introduction of a canula, or a long and elastic, yet firm 
male catheter, will certainly open a channel for its escape. How long 
the instrument should remain will depend upon the evacuation of the 
air, and on the likelihood of irritation and inflammation; nor will the 
management be quite so simple, if adherent masses of placenta, poly- 
poid, or fungoid growths, are the causes of the disease. Some authors, 
in order to effect a permanent cure, advise the injection of the cavity 
of the womb with warm water, weak solutions of chlorine, and chaly- 
beate and astringent lotions. My present experience, independently 
of the frequent dangerous results of such uterine injections, would lead 
me to believe that they can very seldom be necessary. The strong 
alum hip-bath, iron, the various tonics, and in some protracted cases 
mercury and sarsaparilla may be required. 



HYDROMETRA, OR DROPSY OF THE UTERUS. 

History and Symptoms. — This, like physometra, must be regarded 
as a very uncommon disease ; but, unlike the tympanitic affection, 
which is rarely alarming, dropsy of the womb, whether idiopathic or 
symptomatic, is often dangerous. 

Of late, more attention has been given to the morbid condition of the 
uterine lining membrane ; and it has been found that it may, both in 
the natural, impregnated, and puerperal states, as a disease of function, 
secrete and pour forth large quantities of watery and other fluids. Such 
being the fact, it is only farther necessary that the os become closed, 
either by adhesive inflammation, or by some other means, to constitute 
a case of uterine hydrometra. 

As a symptomatic affection there is sufficient evidence that it is not 
an unusual, though certainly a serious malady. Dropsy of the womb 
may, therefore, be considered idiopathic, where, as in Dr. A. T. Thomp- 
son's case, the fluid is secreted by the otherwise healthy mucous mem- 
brane ; and symptomatic , where the secretion, whatever it be, is the 



OF THE CAVITY OF THE UTERUS. 355 

product of tumours, fungi, or ulcerations of the lining membrane ; or 
where the fluid is the consequence of pregnancy or parturition. 

Affections of the uterus, attended with watery discharges, although 
more frequent than formerly supposed, are still so uncommon, that they 
can hardly fail to excite the attention of the physician as well as the 
fears of the patient. Secretions of mucus and pus and losses of blood 
scarcely alarm, except when they are excessive : but discharges of pure 
water are considered the indications of a more alarming state, and con- 
sequently medical advice is early resorted to. It is not affirmed, that 
in every instance such secretions accumulate in the uterine cavity, and 
constitute a genuine dropsy ; they may only partially collect, and the 
os not being firmly or at all closed, their escape maybe nearly con- 
stant. Thus, many of the evils of exhaustion will be present, but 
without uterine enlargement. Being convinced that any information 
on this subject will be useful, I have given below* the substance of a 

* Some years ago, I met with aqueous discharge from the uterus, very soon after 
parturition, and 1 carefully noted the circumstances. Several other cases have since 
that time occurred in my practice, attended by similar symptoms. One of my 
pupils at Guy's Hospital, Mr. Cotton, presented to me the notes of the third ; and 
my friend Mr. Burn, of Earl Street, Blaekfriars, favoured me with the particulars of 
the fourth case. 

1 am desirous to communicate these cases to the profession for two reasons: first, 
because they are important, and attended with danger ; and, secondly, because I can 
find no allusion, much less a history, of a similar disease of function in any obstetric 
author 1 have consulted. 

Discharges of water from the uterus are not unfrequent during gestation, and they 
are occasionally occurring in the unimpregnated condition of the organ. I am, how- 
ever, disposed to think, that the passing away of pints of watery fluid, soon after 
labour, by gush, in the first instance, and afterwards by draining, is a rare occur- 
rence. Had it been otherwise, it would certainly have been noticed in some of the 
valuable works we possess, and it would have become a topic of discussion in medi- 
cal society. 

In the subjoined cases it will be seen that the labours were natural, although 
somewhat protracted and severe. The patients were delicate women, but free from 
serious illness: indeed, there was nothing in the labour, or in the condition of the 
system immediately preceding it, with which the discharge could have been satis- 
factorily associated, as its cause. The principal dangers, connected with this mor- 
bid secretion, appear to be of the inflammatory kind. The weak and rapid pulse, 
the tenderness and enlargement of the uterus, and the almost entire suppression of 
the milk and the lochia, plainly point to puerperal mischief; too likely, when the 
danger is not averted, to terminate unfavourably. It is, perhaps, singular that the 
mucous lining of the uterus should secrete a serous or aqueous discharge, especially 
when such discharge of water is not dependent on the membranes inclosing the 
foetus; but we know that the mucous lining of th« nostril occasionally pours forth 
large quantities of aqueous fluid ; and there seems no reason why, under a like de- 
rangement of function, the lining membrane of the uterus may not do the same. 

That this affection decidedly interferes with the consecutive series of events fol- 
lowing parturition, is evident, from the suppression of the lochia and milk, as well 
as from the scanty secretion of urine : it may, therefore, be placed in the class 
pyrexia. 

I cannot state with certainty what might have been the effect of vigorous antiphlo- 
gistic treatment; because, in the cases related, a modified plan was pursued. As, 
however, the affection may be regarded as catarrh of the uterus, attended by inflam- 
mation, cases will probably occur in which depletion to a greater extent will be re- 
quired. There can be no doubt that the lining membrane of the uterus furnishes 
the discharge. Under natural and healthy puerperal circumstances, the same mem- 



356 ORGANIC DISEASES OF THE MUCOUS MEMBRANE 

paper I published some years since in the Medical Gazette on " Aque- 
ous Discharge from the Uterus after Parturition." The following case, 
which I am now attending with Mr. Allender of Mansell Street, is in- 

brane, then possessing considerable extent of surface, pours forth the lochia. This 
secretion, we know, is at first sanguineous, subsequently it becomes paler, but is still 
mucous ; nor is it till many days have elapsed that it assumes a leucorrhceal or se- 
rous character. The derangement of function, which is productive of this aqueous 
discharge, instead of the lochia, is the disease now described. 

Case I. — Mrs. G was confined on Saturday, November 6th, 1830, of her fifth 

child. The labour was severe, but perfectly natural. 

Sunday, November lih. — Complains of a good deal of pain in the hypogastric re- 
gion ; the uterus is large and tender; pulse 120, but neither full nor strong. Urine 
scantily secreted; scarcely any lochial discharge; and the after-pains not at all 
severe. 

Ordered castor-oil, bran fomentations to the belly, and six grains of Dover's 
powder, in common saline mixture every six hours. 

Monday, 8th, 5 p.m — I was hastily sent for. On my arrival I found the nurse, as 
well as the patient, much alarmed, there having occurred suddenly a very copious 
gush of transparent, colourless, inodorous discharge from the uterus : at least three 
pints had escaped. The bed was wetted entirely through, and a pool had formed 
about the low r er part of the patient's person. The fluid had scarcely any taste, and 
closely resembled water. She was exhausted ; pulse quick, 130; and she was alto- 
gether hurried and alarmed. There was neither tension nor fulness of the mammae, 
indicating the secretion of milk ; the uterus was not so large as on the previous day, 
but very tender to the touch. There has been no lochial secretion, and only a scanty 
discharge of high-coloured urine. She was made comfortable by the removal of the 
wetted linen. A draught composed of thirty minims of aromatic ether and the aro- 
matic spirit of ammonia was immediately given, and she was allowed some bland 
nourishment. The other remedies were ordered to be continued as before. 

Tuesday afternoon, the 9th. — I have seen her several times since last evening. 
The aqueous discharge still continues, twenty napkins having been used : it is not 
at all streaked with blood, nor is there any appearance of lochial or mucous dis- 
charge. After sleep, the water comes away in slight gushes, but by draining at 
other times. The urine is still scanty and high-coloured ; pulse 120, small and cora- 
pre-sible : the breasts are quite flaccid — the child, therefore, is fed. Abdominal ten- 
derness less; uterus better contracted, still reaching half-way between the umbili- 
cus and pubes. 

Continue the remedies. 

Wednesday. — Bow T els have been naturally relieved. Urine still sparing in quan- 
tity and high in colour ; pain of the abdomen less, and uterus not so tender to the 
touch. Pulse 100; debility excessive ; little or no secretion of milk ; aqueous dis- 
charge still very abundant; no lochia. 

After this period, no distressing symptoms occurred, if the languor and extreme 
debility be excepted. The discharge of water continued for twelve days; for the 
last six it was evidently on the decline. The milk was never naturally nor healthily 
secreted ; the child, in consequence, being brought up by hand. 

Case II. — Mrs. T , set. 28, a woman ofspareand delicate habit, and the mother 

of five children, was confined December 8, 1832, of a fine healthy boy, after a natu- 
ral and quick labour. I visited her some hours after, and I found her suffering se- 
verely from after-pains. Pulse 120, sharp, yet compressible. Bladder rather° dis- 
tended, and uterus large. 

Ordered half a grain of opium, and 3 grs. of calomel ; directing a table- 
spoonful of castor oil early on the following morning. 



OF THE CAVITY OF THE UTERUS. 357 

teresting on account of its singularity. Miss is twenty-nine years 

of age, stout, and has hitherto enjoyed tolerable health: menstruation 
has often been irregular, although generally natural in amount and 
character. Five months ago she first discovered that during the flow 
of the catamenia there were discharges of water, which ceased when 

December 9th. — I was requested to see her in the afternoon, in consequence of a 
discharge of water, which had exhausted and alarmed her. I found that she had 
lost between two and three pints of limpid inodorous fluid, and it was still draining 
away. The uterus had descended behind the pubes ; it was not large, but very 
tender. Pulse 130, small and feeble. There had been no lochial discharge, and she 
had passed once a large quantity of urine. 

Ordered bran fomentations, Dover's powder, grs. vj. every six hours ; and 
enjoined perfect quietude. 
This patient went on just as in Case I. only that there was some secretion of milk, 
and the child was partly nursed. She was much debilitated, and the discharge did 
not cease for ten days. 

Case III. — Mrs. P , aet. 40, the wife of a labourer, has had several children ; 

her labours good, with the exception of a temporary state of melancholia. She is of 
sallow complexion, and has ailed greatly during the present gestation. For the last 
three days she has been suffering; and owing to the increase of her pains, the pre- 
sence of Mr. Cotton was requested. Her labour was natural, although severe; and 
there having been copious losses of blood in her preceding deliveries, Mr. Cotton 
bandaged the abdomen, and exhibited 3ss. of the ergot, previously to the expulsion of 
the placenta. Things went on comfortably until the fourth day, when Mr. Cotton 
was sent for. He found his patient had passed a bad night, and complained of severe 
pain in the hypogastric region, which was accompanied with the greatest pain on 
pressure; her pulse was small, 115 ; urine scanty and high-coloured ; and there had 
been a discharge of transparent watery fluid, sufficient to soak from twelve to twenty 
napkins. Bowels confined. 

Leeches and fomentations were ordered to the abdomen ; calomel and 
opium to be given, with an ounce of castor oil, the following morning, 
if the bowels remained unacted upon. 

5th day. — Very low, and in great distress of mind, saying she should never recover. 
Her abdomen was tympanitic, and tender to the touch ; countenance pale, and bow- 
els still unmoved ; her pulse 120, small and weak; the discharge the same in quan- 
9 tity. At the suggestion of a relative, for whom Mr. Cotton attended, he introduced 
the catheter, and drew off eight ounces of high-coloured urine; but this effected no 
mitigation of the symptoms. 

Cataplasms were ordered to the abdomen, and an enema with 01. Tere- 
binthinse, ^jss. exhibited. 

This had the effect of opening the bowels, which greatly relieved the tender and 
painful condition of the abdomen. The pulse also became fuller, 108. 

Pulv. Ipecac, gr. x. were ordered at bed-time. 

On the sixth day she was much improved ; her pulse soft, 100 ; the discharge was 
also lessened, soaking but ten napkins in the twenty-four hours. Light farinaceous 
nutriment was allowed, and saline medicine exhibited. On the eighth day, gra- 
dually getting better; eats with appetite, and the discharge has diminfshed, although 
she still uses from five to ten napkins a-day ; it continues limpid, and devoid of odour. 
Owing to Mr. Cotton leaving the country, he resigned the charge of the case ; but 
he learned that the discharge became by degrees lessened, till at length what was 
left was little in quantity, and very thick in substance. 

It is worthy of observation in this case, that the lochia were suppressed after the 
second day; and there was never any secretion of milk. 

Case IV. — Mrs. T , aged 32, of a spare habit, and delicate state of health, was 

delivered in the forenoon of August 2d, of her first child, a fine healthy living girl, 



358 ORGANIC DISEASES OF THE MUCOUS MEMBRANE 

the period was over. Soon, however, they appeared in the interval, 
and for the last eight or ten weeks she has never been free from watery 
discharge, excepting during the night. On no occasion has.it been 
tinged with blood, and a careful examination shows that the secretion 

after a severe but natural labour of thirty hours' duration. The placenta was ex- 
pelled by the uterine action in about half an hour. The first two days the lochial 
discharge was very profuse and rather offensive, with considerable disturbance of the 
system ; the pulse from 100 to 120 : the countenance pallid, and the lips almost ex- 
sanguineous. There were profuse perspirations ; the abdomen was soft; and there 
was no pain produced by pressure; the secretion of urine was scanty, but passed 
without difficulty. 

On the evening of the fourth day she complained of considerable enlargement of 
the abdomen, but without pain or tenderness ; and on the following morning the 
nurse was hastily called to the bedside, the patient supposing sudden hemorrhage 
had taken place; but on examination, it was found a large flow of colourless fluid 
had been discharged, to the amount of about a quart. This continued for eight days, 
in a quantity sufficient to saturate a dozen napkins in the twenty-four hours. The 
discharge does not dribble away, but escapes in a sudden flow, preceded by a sensa- 
tion of itching, and a slight bearing down. 

9th day — The discharge is evidently abating, as not more than three napkins 
have been wetted with it. 

Mr. Burn remarks in his letter to me, dated fourteen days after the labour, "that 
his patient is still greatly debilitated, and has never experienced any secretion of 
milk. The lochial discharge still continues in small quantity." 

Mr. Bury, of Farnham, subsequently published a somewhat similar case to the 
foregoing, and as he has followed up the history by some exceedingly interesting 
observations, I shall give the communication entire. Mr. Bury remarks : — 

"As my patient unfortunately died, an opportunity was afforded me of performing 
a post-mortem examination, whereby the history is rendered more complete than 
either of those furnished by Dr. Ashwell, and whence, perhaps, some idea of the 
nature of this singular affection may be formed. 

Case. — Tn the month of March, 1833, I attended Mrs. , set. 29, the wife of a 

respectable tradesman in this town, in labour with her fourth child. !She had from 
her youth lived in the enjoyment of what might, in her, be well termed rude health, 
having, however, a goitre since the period of childhood, which had now attained a 
large size, and had increased in magnitude with each gestation, though a certain 
diminution took place after delivery; but within the last few months she had ex- 
perienced a considerable impairment of her general health, to which her looks 
testified. She had become highly " nervous," lost a good deal of flesh, and the 
wonted colour had forsaken her cheeks ; yet her chief complaint was of pain, and a 
sensation of heat in the situation of the left ovary, attended with tenderness under 
pressure. 

The birth of the child was quite natural and expeditious, although there was a 
slight retention of the placenta, owing to a minute adhesion to the left side of the 
uterus, which required to be broken through by the introduction of the hand into 
this cavity. The operation was borne remarkably well, and at the termination of 
the first twenty four hours she was as comfostable as any woman could be. 

When beginning to act upon the bowels, I found that they had been grievously 
neglected during pregnancy. The doses of purgative medicine necessary were there- 
fore unusually great, and the quantities of scybala, and dark and diseased faeces, brought 
away by them were inordinately large. This foul state of the bowels, as might be 
expected, gave rise to a severe form of intestinal irritation, accompanied by a rapid 
pulse of 120, violent palpitation of the heart, pain of head, &c. In short, the symp- 
toms of this disorder, so well delineated by Dr. Marshall Hall, were here conspicu- 
ous. The lochia were natural for the first three days, after which no discharge 
appeared ; and at no period could milk be procured in the breasts despite of all our 
best exertions. 



OF THE CAVITY OF THE UTERUS. 359 

is limpid, very thin, entirely colourless, and free from odour. Nine 
or ten napkins, sometimes more, are soaked through in twenty-four 
hours. Her aspect is unhealthy, her colour gone, and she is losing 
flesh ; the pulse is quicker than natural, but the appetite has not much 
failed, nor are the bowels much constipated ; the urine is scanty, not 
high-coloured, and there is increasing weakness. 

Under the steady and long-continued use of purgatives, the above state of the 
alvine functions was at length rectified, her strength at the same time demanding 
the support of a mild and bland nourishment, and some of the less powerful diffusible 
stimuli. In the space of a month her recovery might be pronounced good, though 
the pain continued in the left iliac region, together with a frequent pulse and un- 
mitigated palpitation. 

In April, 1834, my services, as her accoucheur, were again commanded, and in 
every respect the labour was natural and easy, excepting that there was a greater 
discharge of coagulated blood than usual, both attendant^ and after the expulsion 
of the placenta. 

Her symptoms had been incessantly and carefully watched by me from the earlier 
months of pregnancy, and even before she was pregnant; during the whole of which 
time she had suffered severely from the pain in the left side of the abdomen, as well 
as from pulsation of the heart, and the pulse was scarcely ever under 120. In the 
early months there was a strong disposition in the bowels to become again loaded, 
as during her former period of breeding, and constipation for only one day was 
invariably productive of aggravated sufferings: consequently, when under my advice, 
she took repeated doses of castor oil and laxative electuary as often as they were 
required. 

About the sixth month she went a few miles into the country, to the house of a 
relation ; and whilst there, was bled by a respectable practitioner of a neighbouring 
town, for the relief of the pain in the left iliac fossa. Some alleviation followed the 
loss of blood for a few days, and she was advised to lose more if the pain recurred. 
Nearly a month afterwards, at her own request, I abstracted a few ounces of blood 
from her arm, as the pain was then as severe as ever. On account of the pallid 
aspect of the countenance and prolabia, I was adverse to depleting at all ; and the 
escape of the above small quantity admonished me not to proceed. She fancied her- 
self, however, somewhat easier after this scanty venesection. 

A tendency to swelling had for some weeks been perceptible in the lower extremi- 
ties, and in the face also there were manifest some signs of general effusion ; in fact, 
the aspect of the patient was anasarcuus. And in this critical situation strong fears 
were naturally excited in my mind as to her recovery after parturition. 

The first four days subsequent to her delivery passed over tolerably well, and on 
the fifth some milk was secreted in the mammae. Up to this day the lochial dis- 
charge had been flowing constantly, though sparingly ; but now it ceased, and there 
occurred the very remarkable phenomenon of successive copious discharges of a 
clear watery fluid from the uterine cavity, at intervals of about twelve hours. The 
quantity passed at each time was estimated at two pints, and its accumulation within 
the uterus occasioned much uneasiness, from distention previous to its expulsion, 
which was generally attended with pain. It was perfectly inodorous, and the nap- 
kins were no more stained than if they had been immersed in spring water. For 
the space of six days this singular evacuation lasted, and at the expfration of this 
time, when it terminated rather abruptly, my patient had both rapidly and greatly 
lost ground, and was further irremediably declining in strength. The milk remained 
in the breast only one day. A fatal exhaustion was too plainly approaching; the 
pain in the left ilium and the unnatural action of the heart persisted, though with 
less violence, proportionate to the diminished powers of life. Delirium came on 
three days before her death, which concluded the scene on the seventeenth day after 
her confinement. 

Sectio cadaver is. —All the viscera of the thorax and abdomen were healthy ex- 
cept the uterus and left ovary. The internal surface of the uterus presented three 
elevated masses, having both a fungoid and melanotic appearance, more resembling 



360 ORGANIC DISEASES OF THE MUCOUS MEMBRANE 

The cervix uteri, indeed the whole organ as well as the vagina, is 
healthy, not enlarged, nor at all tender; but having the feel of parts 
constantly under discharge. Alum and catechu are taken internally, 
and the strong alum hip-bath is used every day, with a generous diet. 
These means improved the health, and as during the night the dis- 
charge ceased, the patient was directed to keep her bed, and steadily 
to persevere with the remedies. At the expiration of a fortnight the 
catamenia returned, and during the four or five days they continued to 
flow, there was watery discharge only for two hours. The measures 
formerly adopted were then resumed, and there was no return of the 
serous secretion. When I last heard of this young lady, she had dis- 
continued the use of medicine, and was attending to her usual duties. 

At page 129 I have noticed a peculiar form of leucorrhoea, which 
may be regarded as hydrometra, only that the contents of the uterus, 
instead of being aqueous, are purulent. It may also be mentioned, 
that the excess of the liquor amnii and the false waters between the 
amnion and chorion, are both species of uterine dropsy, though they 
do not belong to this form of the malady. 

The early symptoms are those of irritation, such as indigestion, 
nausea and vomiting, flatulence, pain, and costiveness. If the dropsi- 
cal accumulation becomes considerable, there will be weight and pain- 
ful tension about the pelvis, many of the symptoms of advanced preg- 
nancy, and, according to Carus, slow fever. 

It seems to occur principally in married women, and the accumu- 
lated fluid varies not only in different cases, but in the same case, at 

what has been designated the "rauliflower excrescence" than any other morbid or 
disorganised production to which I could compare them. The largest of these ele- 
vations was about equal in size to a penny piece ; the two others were probably half 
as large. The surface was covered with a thin layer of dark half-coagulable blood ; 
the adventitious substances were intimately adherent to the lining membrane, so that 
they were immovable by the finger or handle of the scalpel. 

In the left ovarium there was nearly half an ounce of pure pus, and the organ 
itself was surrounded by some adhesions formed by coagulable lymph. 

It was unfortunately out of my power to bring away the morbid parts, which 
would have admitted of beino- shown in a drawing. 

I he remarks I have to offer on the foreg-oing case are very few, as I look upon 
those of Dr. Ashwell as peculiarly pertinent, and explanatory of the general nature 
of the subject. It were needless to relate the various means employed in the medi- 
cal treatment, since the detail would be foreign to the object of my present letter. 
Suffice it to say, that no remedy was omitted that held out the hope of relieving such 
formidable symptoms, and that naught but a short palliation of them was procured. 

Like Dr. Ashwell, I had looked in vain for an account or this singular malady in 
the best obstetric authors within my reach ; and yet I cannot but imagine that it has 
fallen under the observation of other practitioners. Now that it has been brought 
before the notice of the profession, it is very probable that instances of the kind will 
be remembered by others, and that in future it will be readily recognised. 

From the actual state of parts found after death, 1 cannot agree with Dr. A. in 
regarding the aqueous discharge as the product of disordered function merely in the 
mucous membrane of the uterus. Whatever might have been the cause of it in the 
cases he has just favoured us with, I have no doubt in my own mind but that, in the 
case which forms the subject of this communication, it proceeded from those foreign 
growths discovered attached to that structure, as it is well known very profuse 
liquid secretions are very general concomitants of such analogous excrescences. 



OF THE CAVITY OF THE UTERUS. 361 

different periods of its progress. Thus, early in the idiopathic variety, 
it is generally serous or mucous, containing albumen, thick and ino- 
dorous ; but, as the disease advances, as proved by examinations 
after death, the contained fluid is dark in colour, thicker and of- 
fensive. 

In the symptomatic hydrometra, the dropsical secretion must of 
course, be frequently mixed with blood or pus, and of various charac- 
ter as to viscidity and odour. Duges instances two fatal cases : in 
one, where death was caused by gangrene of the intestine, there had 
been uterine inflammation, the os was obliterated, and the uterus was 
merely a sac, filled with offensive and dark-coloured pus ; in the other, 
the distention depended on a colourless aqueous fluid, associated with 
cancerous ulceration of the cervix — a case somewhat difficult to un- 
derstand, both as to the quality of the dropsical secretion, and the con- 
dition of the os, which would scarcely be closed in progressive ulce- 
ration of the cervix. Authors differ greatly as to the quantity of fluid, 
the more reasonable assigning the moderate measures of pints and 
quarts, as the usual extent of the dropsy; while abroad, where won- 
ders are more common, Blanchard, in one case, found 85 lbs. of an 
ichorous and oily fluid ; Vesalius, 180 lbs. ; and Bqnet, who need 
not fear competition in the marvellous, relates an instance where 
the uterus, under this disease, was capable of holding a child six 
years old ! 

Menstruation is usually suppressed, although Munro states, that 
amenorrhcea does not always exist. Nauche witnessed milk fever after 
the escape of the fluid, and it is also said, that there has often been 
sympathetic irritation of the mammae. 

The termination is generally by spontaneous evacuation, under 
some physical effort; but some authors relate, that patients thus af- 
fected become exhausted, and die from secondary fever ; or that the 
uterus, incapable of further dilatation, in some weak or thinned portion 
of its structure, gives way, and thus the fluid, escaping into the ab- 
dominal cavity, may induce fatal peritonitis. But such results ought 
not to occur, since the disease is not difficult of diagnosis, and no mis- 
chief can be done by the careful introduction of a proper instrument 
into the uterine cavity for the evacuation of the fluid. I am inclined 
to think, that this affection has been more written about than seen. 
During the last ten years, neither amongst the in nor the numerous 
out-patients of Guy's Hospital has there been a single case. 

Causes. — A blow or fall, by which the abdomen has been injured, 
may produce uterine excitement, and especially affect the mucous 
lining of the organ, thus accounting for the disease ; or the uterine 
dropsy may be the concomitant of a debilitated constitution or of a 
serous diathesis. 

Pathology.— -From what has been said as to the varieties of hydro- 
metra, it will be inferred that the pathological conditions associated 
with it must be different. Thus in Dr. A. T. Thompson's case the 
uterus was perfectly healthy, with the exception of a sphacelated por- 
tion of the peritoneal covering of the fundus ; while in Mr. Coley's of 
Bridgenorth, the womb was entirely diseased : both these interesting 



362 ORGANIC DISEASES OF THE MUCOUS MEMBRANE 

narratives I shall annex, not only because they are authenticated by 
two well-known practitioners, but because they furnish the best descrip- 
tion of the commencement, progress and termination of the malady 
which I have yet read. 

However complicated, therefore, may be the diseased states of the 
womb, two conditions are essential to hydrometra : first, that there 
should be increased secretion from the lining membrane, or from some 
growth or ulceration of its surface ; and, second, that there should be 
impermeability of the channel of the cervix. 

Burns says, that one large hydatid filling the cavity of the organ, 
constitutes the malady ; and Denman once saw an empty cyst of the 
form and size of the uterus, expelled after the discharge of the drop- 
sical fluid it had contained. It is clear that the former celebrated writer 
has not assigned the true cause. 

Treatment. — For this it is sufficient to refer to physometra, the eva- 
cuation of the fluid, the prevention of future accumulation, and the re- 
establishment of the health being the points of especial consequence. 



Case 77. 

related by dr. a. t. thompson. 

Mary Rae, get. 65, mother of several children, was admitted into the infirmary in 
December, 1823 ; she appeared somewhat emaciated, and complained of uneasiness 
and pain, connected with a tumour in the abdomen, which she first perceived about 
six weeks prior to her admission, although from a sense of delicacy she had not men- 
tioned it at the time. It was situated at the lower part of the abdominal cavity, rising, 
as it were, out of the pelvis, and occupying the iliac, hypogastric and umbilical re- 
gions. She appeared as large as if six months gone with child. An indistinct fluc- 
tuation was perceptible in the tumour, and the least pressure on it excited pain. It 
was suspected to be a diseased ovarium, but no examination was made per vaginam, 
nor could it be ascertained from the account the patient gave of its origin, whether 
it had first appeared on either side of the abdomen. The accompanying symptoms, 
however, denoted a greater derangement of the system than usually attends dropsy 
of the ovarium. These were, want of appetite, considerable nausea, furred tongue, 
quick and feeble pulse, the bowels irregular, and the urine scanty and high-coloured. 
(In the beginning of March, 1824, she died, after amputation of the leg, which opera- 
tion had been performed in consequence of a dry gano-rene which had attacked the 
limb.) 

Dissection. — The first object which presented itself, on the abdominal parietes 
being divided and turned aside, was a body, closely resembling the gravid uterus, 
occupying the whole of the pelvic cavity, and the greater part of the abdominal. 
Upon its anterior surface, and firmly adhering to it, was the urinary bladder, con- 
taining a small quantity of dark-coloured urine. On laying the flaps of the abdomi- 
nal parietes together, the stretched bladder was found to extend within an inch of the 
umbilicus; so that it must have been perforated if the trocar had been used to eva- 
cuate the fluid during the life of the patient, under the supposition that the disease 
was ovarian dropsy. The tumour was immediately ascertained to be the uterus, 
greatly enlarged and filled with fluid; it was partially sphacelated on its peritoneal 
covering, at the upper portion of the fundus. With regard to the other viscera, the 
liver was much diminished in size, and adhered to the diaphragm throughout; the 
gall-bladder was large and turgid with deep-coloured bile; the stomach, colon, and 
other intestines with the omentum, were glued together in many places, and some 
were evidently in a state of sphacelation. This gangrenous appearance extended to 
the peritoneum in the hypochondriac region. 

On removing the diseased uterus from the body, and making an incision into it, 



OF THE CAVITY OF THE UTEftUS. 363 

the quantity of fluid which it contained was found to measure eight quarts ; it was 
of dark-brown colour, and coagulated slightly when heated in a spoon over the flame 
of a candle. The existence of a large hydatid within the cyst was expected; but 
this opinion was incorrect, the sac being merely the uterus, in the cavity of which 
the fluid was contained. The internal surface of the organ was not more irregular 
nor more spongy than in its natural state ; but none of the orifices could be found, 
for even the os uteri was, interiorly, as completely obliterated as if it had never ex- 
isted ; and although its situation could be traced in the vagina, yet even there it was 
very faintly marked. The ovaria were small and flaccid, but otherwise natural. 



Case 78. 

reported bt j. m. coley, esq., bridgenorth. 

May 12!k, 1834. — A female, ast. 36, mother of two children, the youngest nine years 
old; had been confined to bed for four months with a tumour in the region of the 
uterus, attended with obstinate constipation, hectic fever, and extreme emaciation. 
On examination, Mr. Coley found a painful irregular tumour in the hypogastrium, 
resembling that produced in the uterus in the sixth month of pregnancy, tender to 
the touch, hard and prominent on the left, and comparatively flattened and elastic on 
the right side of the abdomen. The pain she felt was of a shooting kind, constant, 
and varying in degree of intensity. The os uteri was sound, and a little dilated. 
The cervix was closed, and three-fourths of an inch long. The adjoining parts of 
the distended uterus, within reach of the finger, were of a stony hardness, unequal 
on the surface, and exquisitely tender, especially on the left side. 

The vagina also was tender, and during the last four months, afforded at intervals 
a dark-coloured, offensive, thick discharge, with portions of a membranous substance. 
Menstruation had ceased, and the breasts were enlarged and firm. From her own 
account, it appeared that a year and a half previously, gradual enlargement of the 
abdomen commenced, with suppression of the menses ; that she then believed her- 
self to be pregnant; and that at the end of seven or eight months from the com- 
mencement of this state, a sudden discharge of offensive fluid, with portions of a 
membranous substance, proceeded from, and completely reduced, the volume of the 
uterus. In March, Mr. Coley saw her again, and could discover no fluctuation in 
the uterus, from the vagina. At the latter end of March, there was a slight hemor- 
rhage from the vagina, preceded by the detachment of a thick piece of abnormal 
membrane. About the middle of May, peritonitis occurred ; this was followed by 
purpura, and on the 15th she died. 

Dissection. — May \\th. — Extreme emaciation. Thickening of the serous mem- 
branes, and adhesion of the omentum and abdominal peritoneum to the serous coat 
of the uterus, especially at that part which, during life, felt so hard and irregular. 
Evidences of surrounding peritonitis. 

The fibrous portion or body of the uterus was so disorganised, that it was not 
thicker than an ox's bladder, and in some places it was altogether destroyed by an 
ulcerative process, which had commenced in the mucous membrane. On slight 
pressure being applied, the peritoneal coat at one spot, being free on both surfaces, 
gave way, and a thin, dark-coloured and offensive fluid, resembling that which pro- 
ceeds from an ulcerated intestine, and containing portions of coagulable lymph, to 
the amount of three pints, escaped. The fibrous coat was quite destroyed at other 
parts, as well as the spot where the rupture took place; and the uterus, on being 
divided, collapsed like wash-leather, being generally reduced in thickness to the 
eighth of an inch, and having entirely lost its firmness and elasticity. In short, the 
principal support and figure of the organ were dependent on its indurated peritoneal 
coat, except at the inferior part, near the cervix. 

The whole of the internal or mucous surface of the uterus was found in a state of 
ramollisse merit, or of that species of ulceration observed in the mucous coats of the 
intestines, in certain fatal diseases of these parts. 

The cervix was obliterated, with the gelatinous secretion, peculiar to the state of 
utero-gestation ; and the walls of the uterus, adjacent to that part, were enlarged, 
and consolidated with a tuberculous mass, the principal portion of which was de- 



364 ORGANIC DISEASES OF THE MUCOUS MEMBRANE 

posited in that part which rested against the rectum, and obstructed its passage. 
This morbid production consisted of a uniform white structure, and was free from 
those radiating bands, that grisly feel, and irregular surface, discoverable in scirrhous 
indurations. 



ABSCESS IN THE WALLS OF THE UTERUS. 

This is an exceedingly rare malady, and must not be confounded 
with abscess and ulceration resulting from carcinoma or the other 
malignant diseases of the organ. Instances where inflammation of the 
parenchyma or walls of the uterus terminate in the formation of abscess, 
although thus uncommon, are perhaps more frequent than has been sup- 
posed,°and become the cause of prolonged discharges of purulent and 
sanguineous matter from the rectum or vagina. In such cases, the ab- 
scess communicates by an ulcerated aperture, either with the interior of 
the uterus, the colon, or the rectum. My former clinical clerk at Guy's 
Hospital, Dr. Frederick Bird, has recently published an interesting 
example of the malady ; and as the opening in that case was into the 
bowel, directly the opposite of what occurred in my own, where the 
abscess burst into the cavity of the womb, I shall insert it in his own 
words. 



Case 78. 

For the opportunity of treating the following case, I am indebted to the kindness 
of my colleague, Mr. Bransby Cooper, by whose recommendation the patient was 
placed under my care. 

Miss , aet. 19, is of strumous constitution, and pale. Menstruation has been 

irregular for the last five or six months, and there has been much leueorrhcea. The 
bowels are constipated sometimes, but more frequently relaxed, and for many days 
together there has been no alvine relief, the necessity for it being apparently super- 
seded by the passage of feculent matter per vaginam. On inquiry into the earlier 
symptoms, I found that, deep in the pelvis, and especially when relieving the bowels, 
a month before, she had complained of severe pain. At first, this did not persist 
after the motion ; but shortly afterwards she suffered constantly from stabbing, lan- 
cinating pain in the same situation. A few days before I saw her, she was suddenly 
seized with discharge from the vagina, the singular character and quantity of which 
induced them to ask Mr. Bransby Cooper's and subsequently my advice. On going 
into the chamber, I was shown a pint and a half of discharge, and I had no difficulty, 
from its smell and appearance, in deciding that it was feculent. In the first instance 
it had come away suddenly and by gush, and frequently, in my further attendance, 
T was shown similar, and even larger quantities ; sometimes more, sometimes less 
fluid, occasionally purulent, but invariably feculent, both in odour and appearance. 

I was permitted to examine the uterus per vaginam only once during my attend- 
ance : the neuralgic suffering induced by the examination not subsiding for many 
days. The cervix was tender to the touch, but natural in form, size, and feel. The 
body of the uterus was large, but not indurated ; and when examined by the rectum, 
it was found to be free from all hardness, and the bowel itself quite sound. Iron, 
alum injections, and the alum hip-bath, and good diet, sea-air and bathing were fully 
tried, but only with temporary benefit; her strength declined, and in a few months 
from my first seeing her, she died. Unfortunately the body was not examined. 



OF THE CAVITY OF THE UTERUS. 365 



Case 80. 

CASE OF ABSCESS IN THE WALLS OF THE UTERUS, COMMUNICATING WITH 

THE RECTUM. 

RELATED BY DR. FREDERIC BIRD. 

Mrs. G , aged 37, had, previously to the last three years, enjoyed general 

good health, menstruating regularly. At this date she married, and was soon after 
attacked with acute, deep-seated pain in the hypogastric region, radiating to all 
parts of the pelvis, and increased by micturition and defecation. These symptoms 
were associated with general constitutional disturbance, and, in fact, with all the or- 
dinary symptoms of inflammation affecting the uterus. She passed through the usual 
forms of treatment, and although the more urgent symptoms were mitigated, yet she 
continued to suffer during the three following months from occasional pain in the 
region of the uterus, always produced by attempts at expelling the contents of the 
bladder or rectum, the discharge of feeces being also sometimes effected with great 
difficulty. An internal examination made at this period detected the uterus lower in 
the vagina than usual ; there existed marked enlargement of that organ, the chief 
increase in size being found to occupy the posterior wall ; the os and cervix uteri 
were painful to the touch, and tumid. 

Shortly after the vaginal examination had been made, about half an ounce of pus 
suddenly escaped from the rectum, and she experienced immediate relief from her 
former symptoms. She now became the subject of diarrhoea, generally passing from 
six to eight evacuations daily, each of which contained more or less purulent matter ; 
pain in micturition was no longer felt, but she invariably suffered greatly when 
passing motions. The diarrhoea could not be arrested by any of the remedies em- 
ployed ; her general health, nevertheless, slowly improved, and she went into the 
country, where she remained during the succeeding two years, little or no variation 
in her symptoms having occurred. The diarrhoea, and with it the discharge of pus 
from the rectum, continued ; on some occasions more than a pint of pus has been 
thus evacuated during twenty-four hours, and she observed, that whenever the pus 
failed to be discharged so freely as usual, the local pain became aggravated. During 
the whole of this period menstruation had been very irregular, generally occurring 
at intervals of eight or nine days, accompanied with much lumbar pain and passage 
of coaaula. 

After the lapse of the time mentioned, she again applied to Dr. Bird, suffering 
from nearly all her former symptoms, and, in addition to them, profuse menorrhagia : 
the pain in the region of the uterus was extremely acute, increased by the passage 
of the feeces, and by pressure on the lower part of the abdomen, to which became 
added a neuralgic condition of the genital organs, the slightest pressure upon which 
produced extreme suffering: so great was the pain thus excited, that she was ac- 
customed to employ a mechanical contrivance to prevent the bed-clothes from touch- 
ing the tubes. A vaginal examination was, with much difficulty and pain, again 
made : the uterus was found to be nearly in the same state as before, excepting that 
it had become quite immovable, appearing as if impacted in the pelvis, just as may 
be observed in some forms of malignant disease affecting that organ. No benefit 
resulted from medical treatment, occasional relief only being afforded by large doses 
of opium and the external application of belladonna. 

She continued to suffer from frequent discharges of blood from the vagina, and 
from all her former symptoms, until the lapse of six weeks, when she sank ex- 
hausted by the extreme suffering produced by her disease. 

A post-mortem examination was made twenty-four hours after death. On laying 
open the abdomen, the omentum, small intestines, and all the pelvic viscera, were 
found agglutinated together by peritoneal adhesions of old date. On raising the 
uterus, it was seen to be firmly attached by its upper and posterior portion to the 
rectum ; it presented an irregular form, having the fundus enlarged to about thrice 
24 



366 ORGANIC DISEASES OF THE MUCOUS MEMBRANE 

its natural size. A longitudinal section showed this enlargement to have been pro- 
duced bv an abscess seated in the substance of the wall of the fundus uteri, the cavity 
of which contained about, an ounce of dark thick pus; the walls of the abscess varied 
in thickness from one to three-quarters of an inch, the thinnest portion being nearest 
to the cavity of (he uterus. A communication by means of a short sinus could be 
traced, passing from the cavity of the abscess to the adherent portion of the rectum, 
and opening into that intestine by an aperture sufficiently large to admit of the pas- 
sage of a thick probe, and evidently of old formation. No communication existed 
between the uterine cavity and that of the abscess. The os and cervix presented 
no evidence of malignant disease. The Fallopian tubes and ovaries were adherent 
to the uterus, and could with difficulty be distinguished. The uterus had never 
been impregnated. 



OF UTERLXE MOLES. 

The term mole is by no means accurately defined. All fleshy and 
shapeless masses, irregularly passing from the uterus, are thus desig- 
nated ; for, however authors may differ as to their origin, they seem 
at least to have agreed in bestowing upon them a name sufficiently 
comprehensive, though devoid of precision. Moles may originate 
from the ovum, which has been early blighted, or which has been only 
imperfectly developed ; from a portion of retained placenta ; from the 
firm clots of dysmenorrhea ; from a polypus spontaneously detached 
and shut up in the uterine cavity ; from fibrous portions of coagulated 
blood ; or from the hardened mucus of the uterus itself. 

Thus there are two species of uterine moles : — 

First. — Those which are the product of conception. 

Second. — Those which are independent of pregnancy. 

It is true the majority of such cases may be traced to conception 
as their first cause ; but it is also certain that there are fleshy and 
fibrous moles and hydatids, which do not thus originate. 

Moles resulting from vicious and imperfectly developed ova, differ 
much from each other. Sometimes, although partially organised, 
they are so shapeless as not to resemble any animal form. I have 
seen two such specimens, one the size of the single fist, the other 
as large as both fists doubled, of rounded form, and with an external 
coating like skin. In neither was there any visible development of 
head or extremities, but in one there was the rudiment of an imper- 
fect placenta and something like a navel-string. We have several ex- 
amples in Guy's Hospital Museum of mole, which has been termed 
"the false germ," where the embryo is absent, w r hile the membranes 
are somewhat imperfectly formed. 

All pathologists allow the existence of these moles, however diffe- 
rently they may explain the circumstance of their formation, where 
the embryo having died early, the ovum being retained, has increased 
in size and solidity, not by a process of growth, as in natural preg- 
nancy, nor even as in a tumour or polypus, but by the effusion of 
coagulable lymph from inflammation of the lining membrane. This 
forms successive layers over the surface of the dead ovum, giving it 
eventually a great degree of consolidation. Some of these masses, when 
cut into, have no cavity; but the chorion and amnion are demonstrable, 



OF THE CAVITY OF THE UTERUS. 367 

although the enveloping lymph may be one or two inches in thickness. 
It seems somewhat surprising, that the covering of the foetus should 
be carefully constructed when there is no embryo. But the fact is 
so. Lately, I was present at the expulsion, after much previous flood- 
ing, of a firm, fleshy mass, equalling in size a large orange. The 
small central cavity was lined by a smooth and perfectly formed am- 
nion, with a little fluid ; but although I examined the specimen under 
water most carefully, I could detect no appearance of either embryo or 
umbilical cord. If, in such instances, the embryo has never been 
formed, they may be regarded as genuine examples of false conception. 
Some physiologists, however, have supposed, that in these cases, the 
tender germ may have been accidentally and early deprived of life, and 
subsequently dissolved in the liquor amnii. However explained, the ab- 
sence of the embryo is thus certified. Some years since, in consulta- 
tion with Dr. Arnould, then practising at Peckham, I met with what 
might be fairly regarded as a mole, in the same uterus from which had 
just been removed a living and healthy infant, by the operation of 
turning. The parts of this second foetus must have been originally im- 
perfectly formed. It had died early, and although there was some 
fetid and black liquor amnii, yet the membranes were so thickened by 
the effusion of blood and the deposition of lymph, and the mass was 
altogether so consolidated, as nearly to have lost all definite form. 

[A similar case occurred to the Editor, in which the first foetus died 
at 3 months.] 

Moles originating from conception are longer retained than any 
other species, and it is a natural conclusion, where a considerable time 
elapses prior to their expulsion, that they may, by pressure and the de- 
posit of successive layers of coagulable lymph, degenerate into the 
more solid, fleshy mole. Thus, the conditions of the formation of the 
diseased bodies following conception, are, the death of the embryo, its 
retention in the uterus, its transformation by pressure, and the partial 
organization of the effused blood and lymph into an almost shapeless 
and dense mass. 

Second. — Moles which do not owe their existence to conception. 
These are, as already stated, few 7 in number, when compared with the 
first species. I have seen tw T ice fibrous clots, the product of dysmenor- 
rhoea, growing into mole, and not expelled till they had attained a con- 
siderable size, and then only with great pain and serious hemorrhage. 
Some years ago, I was asked by Dr. Hodgkin to visit a lady a few miles 
from town, who was thought to have polypus. On examination, a 
fleshy and tolerably firm body could be touched, just within the cavity 
of the cervix uteri. There had been considerable bleeding, and the 
anaemia was distressing. Ergot was given, and in a few days the mass 
was protruded through the os. A ligature was placed around it, which 
in twelve hours cut through, bringing away the tumour, but not with- 
out considerable hemorrhage. Ergot was again exhibited, forty minims 
of the tincture every quarter of an hour, and after the sixth dose, a 
fibrous mass, as large as a turkey\s-egg, of firmly coagulated, and par- 
tially organised blood, was expelled. In six or seven weeks, another 
mass, only smaller, was got rid of in the same way. This lady had 



368 ORGANIC DISEASES OF THE MUCOUS MEMBRANE 

long suffered from dysmenorrhea, and had frequently passed firm con- 
crete clots of lymph and blood. There had been no sexual intercourse 
for eighteen months prior to this occurrence. She afterwards died ; 
dropsy of the chest and abdomen having supervened. 

VESICULAR MOLES OR HYDATIDS OF THE UTERUS. 

With regard to the other foreign productions occasionally found in 
the cavity of the womb, so likewise of hydatids, extraordinary and dis- 
cordant opinions have been promulgated ; and it is difficult, if not im- 
possible, to believe many of the wonderful narrations about " false 
gatherings or conceptions" bequeathed to us by the older writers. 

Uterine hydatids are generally pellucid vesicles, varying in size from 
a small currant to a large gooseberry, containing a limpid fluid, capable 
of being partially coagulated by heat and the mineral acids, and, so far 
as my observation has extended, without odour, except when mixed 
with decomposed blood. They grow T , not as in other cavities, single 
and without any connexion, but they are united together by peduncles, 
much in the same way as grapes are to their stalks, only that hydatids 
are generally clustered about a more solid and large central part. _ 

Hydatids, where they are not the product of conception, form in the 
open cavity of the uterus. This circumstance, and the slight closure 
of the os, doubtless favour the disposition to their early expulsion ; for 
although there are marvellous stories told about their accumulating for 
five or six years, and to a vast amount, still it is rare that they go on 
distending the womb for more than four, five, or six months. Their 
quantity is, however, various, and while I have known not more than 
eight ounces of these vesicles to escape, yet in a case I saw with Mr. 
Salmon of Broad Street, there was enough to fill two wash-hand basins. 
Where there are few vesicles, the quantity of fluid in which they float is 
comparatively large ; and where they grow from the ovum, the decidua 
incloses the whole of the diseased mass. To this membrane,— and 
when not resulting from conception, — to an opaque membrane similar 
to it, and connected with the uterine vessels, these hydatids seem to 
owe their nutrition. 

The supposition that these uterine vessels are acephalocysts, and 
have an independent existence, as maintained by Linnaeus and Percy, 
is now entirely abandoned. 

The great danger arises at the time of their coming away ; for, as 
they may be only partially expelled, the hemorrhage may be repeated 
and kept up till their final and complete evacuation. I have known a 
patient alarmingly exhausted by the flooding attendant on these expul- 
sions by instalment. 

Pathology. — These formations are placed in the second species of 
moles, because I have seen at least one example where they were the 
result of diseased action of the uterine lining membrane, independently 
of sexual intercourse. The patient was the widow of a surgeon, and 
of undoubted reputation. Her husband had been dead two years and 
a half when the abdomen began to enlarge. She had nausea, but no 



OF THE CAVITY OF THE UTERUS. 369 

vomiting, from which she had always suffered in her pregnancies. 
The increase of size was very rapid, and at three months and a half 
from the first stoppage of menstruation, the bulk of the uterus had 
reached that of a seventh month's pregnancy. The abdominal tu- 
mour was flaccid, and the os closed. At the fourth month, after more 
than ordinary exertion, there was a gush of blood from the vagina, 
followed by the immediate escape of a considerable quantity of vesi- 
cular hydatids. 

The recovery was good. Iron was afterwards given, she was sent 
to the sea-side, and now, at the expiration of several years, there has 
been no return of the malady. 

Mr. Douglas Fox, surgeon to the Derbyshire Infirmary, gave me 
the particulars of a case where a large mass of vesicular hydatids 
was expelled from the uterus of a maiden lady, where the hymen was 
unruptured, and of whose chastity there could not be a suspicion. 

Sir Charles Clarke and Dr. Blundell unite in opinion, that concep- 
tion is not a necessary condition ; while Madame Boivin, Capuron, 
Duges, and even our own countrymen Denman and Burns, have ar- 
rived at an opposite conclusion. Dr. Every Kennedy says, that " hy- 
datids may occur in virgins ;" while Dr. Montgomery believes, " that 
they invariably result from impregnation." It were to be wished that 
every disputed physiological point admitted, as this does, of a settle- 
ment by the observation of facts. 

Women are liable to a repetition of this vesicular formation, where 
it has resulted from conception. The few exceptions, where the hy- 
datids have formed independently of pregnancy, forbid at present any 
decided opinion as to the probability of their recurrence. 

It cannot, therefore, be concluded, after what has been adduced, 
that the vesicular hydatids necessarily compromise female character. 
Nor need any impropriety of conduct be imputed to a widow, where 
a blighted conception, or these vesicles, shall be expelled after the 
death of her husband. Conception may have occurred during his 
life-time, the ovum may have died, but not being expelled, this morbid 
process is set up, and no one can say how many months may elapse 
prior to the evacuation. 

I have already alluded to inflammation and the effusion of coagula- 
ble lymph, as explanatory of the organization of the more solid moles ; 
while the vesicular hydatids, when it results from pregnancy, is more 
plausibly attributed to disease of the flocculi of the chorion, which, on 
close inspection, will be found to present the commencement of these 
vesicular growths. Even in the same mass, the cysts may be observed 
in progress ; some just beginning, others being more distinct and trans- 
parent ; while those which are fully formed contain fluid, and may be 
regarded as perfect hydatids. 

Dr. Montgomery has a preparation showing " the ovum completely 
covered by the decidua reflexa ; but when that was turned back, the 
hydatids were seen growing from the villous surface of the chorion. 
There was another peculiarity in their mode of attachment and growth, 
worthy of notice. At first one or two sprung from a single, fine, thread- 
like stalk, then from these one or two more, and so on, until at length 



370 ORGANIC DISEASES OF THE MUCOUS MEMBRANE 

a large bunch of hydatids was formed, hanging from the chorion by 
the original delicate single stalk." Now, while it may be granted that 
in the greater number of examples these productions originate indirectly - 
from pregnancy, I am convinced such an origin is not universal. The 
cases already mentioned prove this : at least, so far as I can judge, they 
establish the fact, that vesicles so like the hydatids of the chorion as 
not to be distinguished from them by the eye, do very rarely grow from 
the diseased lining membrane of the uteri of unmarried women and 

virgins. 

The true hydatid (the acephalocyst or cysticercus) is found also in 
the uterus. But in its seat and mode of generation, it differs from the 
vesicular hydatid. The latter I have never known produced in the 
substance of the womb, the decidua and lining membrane constituting 
its nidus or base ; but the true hydatid may form in the parenchyma or 
walls of the uterus, in the same way that it grows in the liver or mus- 
cular tissue of other parts of the body. Some years since Mr. Wilton 
of Brighton (vide an excellent lecture by Dr. Ingleby, on Hydatids of 
the Womb, Lancet, February 1, 1840) detailed a very interesting case 
of hydatid formation. The patient died, and when the body was ex- 
amined, a highly varicose state of the veins was seen at the posterior 
surface of the fundus, beneath the peritoneum, constituting a rounded 
tumour. In the diseased part there was an opening, which contained 
a coagulum. This opening was proved to be the immediate cause of 
death, by an effusion of blood in the abdomen, to the extent of seve- 
ral quarts. A mass of hydatids protruded into the cavity of the womb, 
portions of the mass being firmly adherent to it. In the vicinity of this 
mass the lining membrane had degenerated in character, and was co- 
vered by patches of lymph. On the removal of the adherent hydatids 
it was found that the lining membrane was partly wanting, and that 
masses of hydatids were imbedded in the structure of the organ. To- 
wards the fundus they existed in nests of various sizes, and produced 
the rounded tumour at the posterior surface of the fundus, which has 
already been described. These, I presume, were true hydatid forma- 
tions, very different from the vesicles generated in the chorion, as the 
result of a blighted conception. 

Dr. Andrews (vide Glasgow Medical Journal, No. 4) published se- 
veral cases of hydatids simulating pregnancy. Two of them were in 
married women, the other two in girls of the ages of sixteen and seven- 
teen years. In one, menstruation had never occurred, and the hymen 
was entire. The advocate of pregnancy, as the sole origin of vesicular 
hydatids, will of course think these were examples of the true or ace- 
phalocyst form of the disease : and without very accurate investiga- 
tion, it would be difficult to determine in which class they ought to be 
placed. 

I have once or twice examined slightly pellucid and bladder-like 
substances, which have passed during and after dysmenorrhea, but 
they could not have been mistaken for hydatids. 

It is quite possible, during hydatid pregnancy, if any considerable 
portion of the lining membrane is unoccupied, that it may be largely 
supplied with blood, and may thus furnish watery discharge, indepen- 



OF THE CAVITY OF THE UTERUS. 371 

dently of the breaking of the cysts or of their subsequent escape. 
This is a practical fact of some importance, as tending to explain the 
occasional gushes of watery secretion, not succeeded either by the par- 
tial or entire emptying of the womb. 

For the following particulars I am indebted to Dr. Ingleby. The 
case occurred in the practice of Mr. Chavasse. — " A lady was attacked 
about the fifth month of her pregnancy by hemorrhage and pain, ac- 
companied by the expulsion of a mass of hydatids, probably three or 
four ounces. The hemorrhage ceased for a short time, but returned at 
intervals for upwards of a year, and was attended occasionally by se- 
vere pain and the expulsion of a single hydatid resembling a hot-house 
grape. The symptoms became more alarming, the hemorrhage resist- 
ing every mode of treatment which could be devised. A state of anse- 
mia ultimately ensued, and, on the conviction that the patient's life 
depended on the removal of the hemorrhage, it was determined to use 
a stimulating injection. The third injection was impregnated with 
oxide of iron, and, after using it several times, its strength was in- 
creased by the addition of one drop of the tinctura ferri sesquichioridi 
to each oiiHce of the oxide injection, and gradually increasing the 
quantity of the tincture to four drops. Its employment was followed 
by so much pain and tenderness, as not only to require a suspension of 
the injection, but also to demand a mild antiphlogistic treatment. At 
one time severe inflammation supervened, and the patient seemed to 
be sinking under irritative fever, but after this no further discharge 
took place ; but at length, under the tonic plan of treatment, she per- 
fectly recovered, and the uterus has since resumed its natural functions. 
In this case removal of the disease is clearly referable to the stimu- 
lating action of the iron on the lining membrane. The treatment of 
acephalocysts in the uterus by iron has much to recommend it ; that 
metal, indeed, has been supposed to exert a specific action in such 
cases. However this may be, the principle is quite inapplicable to the 
hydatid formations of pregnancy, and injections of iron can only act 
like stimulating injections generally." 

Symptoms and Diagnosis. — The symptoms closely resemble the first 
signs of pregnancy, and the diagnosis is rarely attempted until the time 
approaches for the earlier indications to be confirmed by the move- 
ments of the foetus. About this period, or sooner, doubt generally 
arises. The catamenia have disappeared, and the abdomen has be- 
come enlarged ; the uterine tumour may have been distinctly felt, and, 
together with the increased volume of the breasts, may have settled the 
point that pregnancy really exists. But there is no quickening, and 
the patient is often disproportionately large. Thus, if half the term 
only has passed, the bulk may equal that of a pregnancy nearly at its 
close, and the greater part of this vast increase may have occurred 
within a few weeks. If a medical opinion is now asked, additional 
reasons for suspicion will soon be discovered. The stethoscope will 
fail to detect the pulsations of the fetal heart, or even the placentary 
murmur; there will be no balancing the uterine contents by the " bal- 
lottement ;" and the womb, although greatly distended, will be soft and 



372 ORGANIC DISEASES OF THE MUCOUS MEMBRANE 

doughy in feel, exceedingly unlike the firm structure of the impregnated 
organ. 

There are, too, occasionally other symptoms leading to the conclu- 
sion that there is disease. Severe pain is sometimes the attendant of 
this rapid uterine growth (vide Case 82), and pressure of the tumour 
often produces uneasiness. The pulse is quick and there is a degree 
of general illness, rare in natural gestation. Some authors affirm, that 
there is a serous or sanguineous vaginal discharge ; and this may be 
true if it be limited to a few weeks prior to the expulsion of the hydatid 
masses. There are cases where the health is but little disturbed, either 
constitutionally or from the enlarging uterus, beyond what is common 
in healthy pregnancy. By the vaginal examination the diagnosis will 
not be much assisted (excepting the absence of the " ballottement"), as 
the cervix is diminished in length, is much broader and softer, and the 
body of the womb is felt to be greatly enlarged. 

Thus, while it may not be easy to say what the uterine contents 
really are, it will not be difficult to determine that natural pregnancy 
does not exist. Physometra and hydrometra are such uncommon ma- 
ladies (vide their histories) that they will hardly perplex the prac- 
titioner. In the former, so far as that the accumulation of air shall 
equal the bulk of the pregnant uterus in the fourth month, I am hardly 
a believer ; but if such a case should ever occur, its less weight and its 
resonant elasticity will serve as guides. 

From hydrometra, hydatid accumulation may be readily distinguished 
by the absence of distinct fluctuation, as it is next to impossible to sup- 
pose that the uterus shall contain pints of fluid without fluctuation. In 
some instances, one or two of the vesicles escape, and if recognised, 
the disease is of course at once understood. 

Prognosis. — This cannot always be favourable. If the patient be 
young and otherwise healthy ; if the disease has not lasted long ; if it 
be a first occurrence ; and if the hemorrhage has been moderate — a 
satisfactory opinion may be safely given. Where, however, it occurs 
later, perhaps between forty and fifty, or at the period of catameniai 
decline ; where there have been frequent pregnancies and exhausting 
sucklings ; abortions, and a series of events unfavourable to health, a 
much more guarded prognosis is necessary. In such instances (vide 
Cases 81 and 82,) the decay of constitutional strength, dropsy and 
phthisis, or possibly organic and malignant uterine disease, may be the 
results. 

Treatment. — We may say of uterine hydatids, as of placentar pre- 
sentations, that their accurate diagnosis lessens, but does not remove 
anxiety. In hydatids, there may be no present hemorrhage and there- 
fore no necessity for interference ; but it is impossible to say when, or 
to what degree bleeding may take place. There are instances where 
the expulsive contractions come on at once, and without any previous 
hemorrhage ; but it is far more common that bleeding occurs several, 
perhaps many times before the uterus is completely emptied. The diffi- 
culty of the treatment consists in knowing precisely when and to w^hat 
extent we ought to aid these expulsive efforts. To do so prematurely 
and unnecessarily, especially when the neck of the uterus is but slightly 



OF THE CAVITY OF THE UTERUS. 373 

developed, would be to incur the almost certain dangers of contusion 
and inflammation. To allow the bleeding to exhaust the patient, with- 
out any active measures to produce expulsion, would expose the prac- 
titioner to severe censure. It is rare for the uterus, if excited to mode- 
rately vigorous contraction, to become again entirely quiescent ; and if, 
when these efforts are perceived, two or three doses of ergot are ex- 
hibited, and a bandage applied round the abdomen, we shall not often 
be disappointed in obtaining complete evacuation. 

If, however, such should be the case, and the small degree of de- 
velopment of the cervix forbids the introduction of the hand, the va- 
gina should be plugged with soft tow, cold should be applied over the 
vulva and thighs, and the prompt treatment so essential in large uterine 
bleedings should be at once adopted. There are probably few cases 
of large and dangerous bleedings, where the hand, if necessary, may 
not, gradually and gently, be safely introduced into the uterine cavity 
for the express purpose of bringing away the hydatids. It is scarcely 
necessary to say, that the same care and watchfulness are necessary 
after such events, as after flooding labour. 

Nor can it be too strongly recommended, that no risk of a fresh 
pregnancy be incurred for some time after the health is fully established. 



Case 81. 
enlargement of the uterus from vesicular hydatids. 

On June 25th, 1831, I was requested to see a lady who had been occasionally un- 
der the care of Mr. Salmon of Broad Street. 

Mrs. is nearly 50, and has had ten children, but has not been pregnant for 

the last eight years. 'I ill February, menstruation was regular, and its subsequent dis- 
appearance was attributed to conception. In April and May she had nausea and sick- 
ness, and was incommoded by several of the early signs of gestation. Snon after- 
wards, in the last week of May, there was slight hemorrhage, and she has never 
since been free from uterine bleeding for more than twenty-four hours. Her gene- 
ral health is greatly impaired ; she is emaciated, the pulse ranges from 120 to 140, 
and she is very irritable and anxious. 

On examining the abdomen externally, there may be felt a well-defined, round, 
and central tumour, reaching from the pubis to considerably above the umbilicus ; 
but it is soft and fluctuating, exceedingly unlike the firm consistence of healthy 
pregnancy. The umbilicus is prominent, and the abdominal integuments are only 
slightly tense. Internally the os uteri is supple and open, admitting easily the first 
phalanx of the forefinger; the cervix is developed, and has lost nearly two-thirds of 
its length, reminding one of the seventh month of gestation. The body of the ute- 
rus is balloon-shaped, and easily raised by pressure on the cervix. 1 cannot, how- 
ever, displace the uterine contents by pressure, either on the abdomen or cervix; 
nor can I discover anything like a child. There is not any appreciable disease in 
the abdominal viscera, and the parietes of the uterus seem healthy. Thus the dis- 
proportionate bulk, the bleedings, the open state of the os, the softness of the uterine 
tumour, and the entire absence of the ballottement and of the foetal movements, con- 
firm the impression, that although impregnation may have occurred, its results are 
destroyed by hydatid growths. 

For ten or twelve days, .1 was anxious about the patient, as the hemorrhages were 
frequent, sudden, and large; and having administered the ergot, as I found, without 
advantage, 1 had determined, within the next four hours, to empty the uterus. Just, 
however, as I was leaving the house, pains came on, and in the course of half an 



374 ORGANIC DISEASES OF THE MUCOUS MEMBRANE 

hour two wash-hand basins full of uterine vesicles were expelled. Nothing of mo- 
ment occurred afterwards, excepting that the recovery was slow and incomplete; 
and when I saw her a few months subsequently, she was still emaciated, very thin, 
had cough and night sweats. In a short time confirmed phthisis set in, and within the 
year she died. 

I was informed by Mr. Street of Norwood, who examined the body after death, 
that the uterus was large and very soft, and that its lining membrane, contiguous to 
the mouth and round the lower part of the cavity, was ulcerated. 



Case 82. 

reported by mr. george stanger, surgeon at nottingham. 

Mrs. , aet. 40, the mother of several children, came to the Dispensary, com- 
plaining of severe pain in the abdomen. On examining, I found a large tumour, 
centrally placed but soft, of the size of a seventh month's pregnancy, and of a globu- 
lar rather than longitudinal form. The catamenia had disappeared for three months. 
Neither bleeding nor purging relieved the pain; but in a few days a large hemor- 
rhage from the uterus occurred, which; although attended by extreme prostration, 
mitigated the severity of the pain. On examination, I found the os patulous, and it 
was evident the uterus was filled with something tolerably hard, a child, or fleshy 
mole or hydatids. Brandy was freely given, and ergot was prescribed ; but before 
the latter could be administered, she was seized w r ith violent labour-pains, and ex- 
pelled nearly a bucketful of uterine hydatids, connected with, and apparently grow- 
ing from, a placentar-like mass. Her convalescence was protracted. 

Mr. Stanger informs me, that within two months the abdomen began again to en- 
large, and the same severe painsreturned, her health was failing rapidly, and he feared 
she would sink. 

I have selected these out of a number of cases of the disease, as 
although the course of symptoms is well pourtrayed, the result having 
been fatal in both, they are calculated in other examples of the malady to 
secure the watchful care of the practitioner. 



OSSEOUS AND CALCAREOUS TUMOURS OF THE CAVITY OF THE 

UTERUS. 

Already, at page 213, I have alluded to the increased induration of 
the fibrous tumours of the uterus, even to the extent of cartilaginous, 
osseous, or calcareous hardness. Nor is there any doubt, that the 
womb stones described by the older pathologists, were originally fibrous 
or hard tumours, in which this transformation had occurred. To this 
degeneration fibrous growths are especially prone ; and it has been 
formerly pointed out, that one of the most satisfactory results of any 
treatment which they may require, is the continuance of their natural 
low degree of vitality. In this quiescent state, they may continue 
during the remainder of life, producing, if any, only slight mechanical 
inconvenience. Or if, on being originally located in the uterine parietes, 
they shall, by pressure from their increased hardness, ulcerate through 
the mucous lining into the cavity of the uterus itself, such an occur- 



OF THE CAVITY OF THE UTERUS. 375 

rence, especially at an advanced period of life, will scarcely produce 
any aggravated sufferings. We have in Guy's Museum several speci- 
mens of these calcareous tumours, the largest of which was removed 
from the uterus of an aged subject brought for dissection. The history, 
had it been known, would probably have confirmed the truth of the 
preceding remarks. I have occasionally under my care an elderly lady, 
in whose uterus I feel sure there is one of these womb stones ; and she 
states, that when she first became aware of the central and hard swell- 
ing, she frequently suffered from pains nearly as expulsive as those of 
labour. Shortly, however, menstruation ceased, and from that time, 
now nearly twenty years, there has been no return of the uterine con- 
tractions. 

Professor Simpson of Edinburgh, to the learning and value of whose 
writings 1 am glad to pay the respect they deserve, says, " that he has 
had repeated opportunities of remarking calcareous degeneration equally 
in the very smallest fibrous tumours, and in those of larger size." 

In the following opinion I fully concur: — "Fibrous tumours may," 
the Professor says, " in some rare cases, undergo another or cellular 
form of transformation, and in this way become diminished both in 
density and volume. It is only by this kind of cellular atrophy that 
we can explain the circumstance of the disappearance to a greater or 
less degree of uterine tumours that appeared to have all the characters 
of fibrous tumour. We have lately had an opportunity of watching 
one such case, and there are a few others on record. The appearances 
after death in some instances of this kind, would make a great addition 
to our present knowledge." 

It is clear, that little need be said about treatment. What has 
already been advanced as to soothing the irritation, existing either in 
the fibrous tumours themselves, or in surrounding parts, is applicable 
here ; nor would any practitioner hesitate to aid any efforts for the ex- 
pulsion of such bodies from the uterine cavity. 

■ 

PHLEBOLITES 

Are bodies generally of small size, and varying in structure and 
density from a mass of fibrin to one of calcareous hardness, found in 
the uterine and pelvic veins. Lately I was present at an inspection 
where several of these productions, of varying consistence, were dis- 
covered. There are not, to my knowledge, any symptoms which 
would, during the life of the individual, indicate their existence. 

ATROPHY AND HYPERTROPHY OF THE UTERUS. 

The former of these states is not uncommon in very aged women, 
and in these it can scarcely be considered a disease. I am inclined to 
think, that atrophy of the uterus and ovaries is more common in the 
early and middle periods of life, than is supposed ; but as death, under 
such circumstances, is happily of rare occurrence, it is difficult to bring 
pathological evidence to support the opinion. Frequent sterility, how- 



376 ORGANIC DISEASES OF THE MUCOUS MEMBRANE, ETC. 

ever, lends some probability to its correctness ; and it could scarcely 
do harm if iron, and the various means for the cure of chlorosis, were 
earlier and more vigorously employed, in cases where, from the gene- 
rally attenuated condition of the patient, the reproductive organs might, 
probably with truth, be thought to participate in the ansemia. It is 
almost certain, that congestion of the uterus, which is often permitted 
to continue for years without curative local depletion, lays the founda- 
tion of sterility and of slowly advancing atrophy, both of the uterus and 

ovaries. ' , . . ' 

Hypertrophy of the uterus is more common than atrophy; and it is well 
known how frequently, in the neighbourhood of polypi and sub-mucous 
and fibrous tumours, the uterine walls become very much thickened, 
and their blood-vessels proportionately increased. Such diseased con- 
ditions may in many cases be unknown ; but the probability of their 
existence shows how necessary it is to examine, not once only, but 
repeatedly, and not by the vagina alone, but also by the rectum. I 
have seen instances of a generally hypertrophied womb independently 
of organic disease : but such are rare ; and I am now attending the wife 
of a medical friend, where many of the symptoms of a large uterus ex- 
ist without indication of tumour. There is much more to be effected 
by treatment in hypertrophy than in confirmed atrophy. 



CHAPTER VI. 
DISPLACEMENTS OF THE UTERUS. 

This is a most extensive subject, and in treating it, I shall endeavour 
to be as practical as possible. The situation of the uterus, and its 
method of support, are admirably adapted to the functions it has to 
perform. But while this is fully conceded, it must also be allowed, 
that these very circumstances render it peculiarly liable to displacement. 
Its ligaments are not strong, and the broad expansions of peritoneum 
fixing it to the sides of the pelvis, are, of necessity, elastic. The blad- 
der may exceed its natural fulness, and thus push backwards the uterus, 
to which it is so intimately connected ; while the rectum, when exces- 
sively loaded, may seriously derange its central position. The vagina, 
an organ of such diversified function, may become relaxed and capa- 
cious, and thus permit a trivial descent or a complete protrusion beyond 
the external organs. Add to these facts, the necessary alteration of 
position during pregnancy, and then, independently of tumours and 
diseased enlargements of the abdominal and pelvic viscera, we have 
sufficient proof, that of all the organs of the body, the uterus must be 
most exposed to displacement. 

Being more common than any other, I shall commence with those 
deviations in which the uterus descends or sinks lower than natural, 
towards the outlet of the pelvis. 

Relaxation, prolapsus , and procidentia are the three degrees of this, 
the most frequent of all the uterine displacements. 

Relaxation* implies, that the uterus has lost its central projecting posi- 
tion in the upper part of the vagina, and has descended sufficiently far 
to obtain a bearing on the perinseum ; without, however, any material 
shortening of this canal, or any marked alteration in the uterine axis. 

Prolapsus signifies, that the uterus has sunk nearly, or quite down to 
the os externum. Under this state, the vagina is considerably everted, 
and the womb, losing the axis of the brim, which is downwards and back- 
wards, assumes the axis of the outlet or of the vagina, which is down- 
wards and forwards. 

Procidentia implies complete protrusion beyond the vulva. The 
uterus forms a tumour, often very large, hanging out between the 
thighs ; and the vagina turned inside out, constitutes the external 
covering. In the sack thus formed, especially if of long standing and 
large, there is contained the bladder, rectum, and some portion of 
the small intestines, the mesentery being stretched, and the omentum 
occupying any vacant space. 

* [This seems to be an unnecessary refinement, as a prolapsed uterus is found in 
various positions, if examined, several times in one day even. — Am. Ed.] 



378 DISPLACEMENTS OF THE UTERUS. 

History and Causes. — There are few diseases about which medical 
writers of the present da}' are more perfectly agreed. The ancients, on 
the contrary, doubted the possibility of the uterus being entirely pro- 
truded, giving, as their reason, the strong support afforded by its liga- 
ments. Now, from the anatomy of the parts, we scarcely attribute any- 
retaining or holding power to the uterine ligaments. By experiments, 
too, on the dead body, Professor Burns found, that more resistance was 
afforded to procidentia by the connexion of the uterus and vagina to 
the neighbouring parts, than by the agency of the ligaments ; for al- 
though he cut the ligaments, he could not, without much force, make 
the uterus protrude. At this result I also arrived, by a repetition of 
the practice. A debility and relaxation of the levator ani and perineal 
muscles, but particularly an extension and slackness of the pelvic fascia, 
in its connexion with the uterus and vagina, are in a great measure es- 
sential to the production of the prolapsus. 

Of all the chronic female diseases, displacement is the most common, 
often existing long in slight degree, without being suspected ; while even 
serious prolapse and decided procidentia, have within my own know- 
ledge been allowed to continue for many months without medical aid. 
Nor must it be - supposed, that married women and mothers are its only 
subjects, as two of the worst cases in Guy's Hospital were in young 
unmarried girls. There can be no doubt, that it is more general among 
the poor than the rich, and that marriage and parturition are predis- 
posing causes. Capuron says it is most common in married females be- 
yond the middle age ; and it must be granted, that the more numerous 
the children the more are the passages in a condition favourable to the 
displacement of the pelvic contents. Dr. Alexander Monro relates a 
case occurring in a girl of three years old. Two examples of prolapse, 
where the womb was all but external, has come under my notice, and 
in neither had puberty been fully developed. They were both stru- 
mous girls, and being nurse-maids, had to carry heavy children, thus 
accounting for the early appearance of the malady. 

Complete procidentia is sometimes produced, where the uterus is 
of normal size ; or where, being unimpregnated, its volume has been 
increased by hard or scirrhous growths, polypi, hydatids or moles 
affecting its walls or cavity. 

Early pregnancy has often induced prolapse from increased weight, 
while the severity and protraction of labour have had a like effect. 
Nor must it be forgotten that ascites, a dropsical ovary, or any adven- 
titious tumour in the neighbourhood of the uterus, may induce a similar 
result. 

There has been a considerable difference of opinion as to the real 
pathological causes. These, however, are principally — 

1. Increased capacity and relaxation of the vagina. 

2. Weakness and undue expansion of the broad and round ligaments of 
the uterus. 

Without denying the influence of the latter of these states, it is im- 
possible, I think, not to allow to the former the principal share in the 
production of the descent. Still it would be wrong, if elongation of 
the uterine ligaments were excluded as a cause of the disease ; as it 



DISPLACEMENTS OF THE UTERUS. 379 

must be evident, however little their relaxation may contribute to slight 
sinking of the womb, that its complete prolapse cannot occur without 
their being considerably stretched and elongated. 

Little doubt can exist in the minds of those who have carefully 
studied the anatomy of the pelvic viscera, that the vagina, bladder, and 
rectum, together with the muscles lining the cavity of the pelvis, have 
the greater share in maintaining the uterus in its natural position. 

Still displacement beyond the vulva may occur in virgins, although 
it is rare to find even slight prolapse associated with a healthy and to- 
lerably contracted vagina. Not a little, however, must be attributed to 
the kind of effort immediately preceding the descent. If, for example, 
prior to or during menstruation or pregnancy, or early in the puerperal 
month, before the uterus has resumed its unimpregnated size, there 

should be a blow or fall, or inordinate and sudden physical exertion 

under such circumstances, the uterus may, without any morbid relaxa- 
tion of its ligaments or increased size of the vagina, be at once pushed 
down beyond the external parts. If such descent continue, it will be 
seen, that stretching of the ligaments, and of every tissue connecting 
the pelvic viscera and distention of the vagina, must be the consequence, 
and not the cause of the displacement. 

Nor can it be disputed, that fibrous or scirrhous tumours, till they 
attain a bulk too great to allow of their being retained in the pelvic 
cavity, must act entirely independent of either of those chief causes 
already pointed out. But where the vagina and its orifice are much 
dilated from frequent child-bearing, leucorrhosa, excessive menorrhagia, 
or uterine hemorrhage, the displacement is the effect of these states, 
and easily induced by cough, sneezing, or vomiting, especially if the 
bladder or intestines be full, or indeed by any slight downward forcing 
of the abdominal viscera. 

Congestion of the uterus is thought by M. Lisfranc to be the most 
universal cause ; but the opinion is probably inaccurate. In numerous 
instances I have seen the organ congested without any descent ; and 
frequently, even in entire procidence, I have been unable to discover 
more than very slight increase in its bulk. 

Dr. Fleming mentions, that he has witnessed the malady as the con- 
sequence of ascites ; and I am confident that a woman with a large 
pelvis, and consequently a short vagina, is especially prone to it. I 
concur in M. Jourdan's observation, that it is more common in thin 
than fat women. 

But, certainly the malady, in all its complete forms, is more frequently 
the result of labour and the too early resumption of the upright posture, 
than of all other causes combined.' Mr. Roberton's able and careful 
researches have determined this point. In early pregnancy the addi- 
tional weight of the uterus often occasions slight depression ; and a simi- 
lar result, accompanied with vaginal heat and pain, ensues in delicate 
females, apart from pregnancy or marriage, as the consequence of long- 
continued leucorrhcea. I have frequently known the first symptoms in- 
dicating prolapse, to have occurred in young unmarried women after 
dancing, running, or too severe exertion during menstruation. In this 
way, complete procidentia (the uterus hanging pendulous between the 



380 DISPLACEMENTS OF THE UTERUS. 

thighs) had been produced in a young single woman, a patient of mine 
at Guy's. Such results are a strong motive to quietude, at least in 
delicate women, while menstruating ; as, during this process, owing to 
the increased weight of the organ, the uterine ligaments are stretched, 
and therefore weakened ; in fact, every part connected with the uterus 
is soft and flabby ; the vagina participating so fully in this relaxed con- 
dition, that it is easy to understand how any sudden and violent 
exertion may produce' displacement. [One of the worst cases which I 
have ever seen in an unmarried woman was produced by a fall from 
a horse, in a sitting position, on the soft tan of a riding-school, during 
menstruation.— Am. Ed.] Dr. Davis almost entirely precluded the 
agency of a morbidly capacious vagina in the production of de- 
scent of the uterus; but, as it appears to me, on very insufficient 
grounds, and with a total disregard of the fact, that prolapse and pro- 
cidentia are never found coexisting with a vagina of natural size ; at 
least I have never seen these degrees of displacement without this canal 
being too large and distensible. 

Symptoms. — These are sympathetic in the earlier stages, and me- 
chanical in the more established and chronic disease. Irritable women, 
and those who have been tenderly and luxuriously brought up, suffer 
much even from the slightest sinking of the uterus; while strong women 
in the lower ranks of life almost entirely disregard these early incon- 
veniences, and complain but little even when the organ is entirely pro- 
cident, of large size, and extensively ulcerated. I was much struck 
lately by a contrast of this kind ; a lady, wealthy and self-indulgent, 
from over-exertion in dancing, while the catamenia were present, dis- 
placed the uterus very slightly, so slightly, that in a day or two h was 
only just resting on the perinaBum ; yet she never stirred off the sofa for 
a month. At the same time I had under my care a poor woman, earn- 
ing her living by carrying vegetables on her head to and from market, 
whose uterus, as large as a good-sized melon, was entirely out of the 
vagina, and ulcerated. She merely wanted to be relieved from the 
acrimony of the discharge, scarcely complaining at all of the mechanical 
inconveniences of weight and position. Doubtless relaxation of the 
organ frequently exists without being recognised, as the early symp- 
toms of lumbar weight and uneasiness are indications too common to 
be soon attributed to displacement. But when these have continued 
long, nausea, loss of appetite, constipation and flatulence being added 
to them, suspicion is excited. It is then found, that standing or walk- 
ing aggravates the symptoms, and that the recumbent posture alone 
gives certain and immediate relief. Almost constant leucorrhoea and 
occasional strangury claim attention. Thus week after week passes 
away ; and remedy after remedy is tried ; the patient ultimately soli- 
citing an examination, that the disease being accurately made out, 
something more curative may be tried. 

In the commencement of the disease, a vaginal investigation will 
detect a sinking only of the uterus : it will have lost its normal position 
in the centre of the pelvis ; and instead of being three or four inches 
from the orifice of the canal, the cervix will be found resting on the 
perinseum, which it ought not to touch, and within an inch or two of 



DISPLACEMENTS OF THE UTERUS. 381 

the vaginal orifice ; the vagina itself being generally moister than na- 
tural, loose and corrugated, or capacious and smooth. 

In complete procidentia the symptoms vary much, partly arising from 
the size and protrusion of the uterus ; the susceptibility of the patient; 
and the extent to which the bladder and rectum and other organs may 
be affected. 

Cases are on record where the bulk of the procident womb was enor- 
mous, reaching nearly half-way towards the knees ; and on several 
occasions in hospital practice, I have seen the organ irreducible and of 
vast size. Nor even then, are the mechanical inconveniences so in- 
tolerable as might be supposed. During menstruation and very hot 
weather, there is much suffering; but in general some contrivance is 
adopted by which the womb is shielded from pressure, and thus these 
women continue to go through their daily work. Sometimes, however, 
abrasion passes into ulceration, when the pain and the discharge com- 
pel quietude and the relief of a hospital. Many such cases are yearly 
admitted into our female wards. Menstruation is rarely disturbed, noV 
are hemorrhagic or uterine bleedings at all common. The functions 
of the uterine system indeed are scarcely deranged by this complete 
derangement of position ; even conception takes place, and there are 
examples where its occurrence might have been deemed almost an 
impossibility. 

One day at Guy's, a woman, about 50, presented herself amongst 
the out-patients for complete procidentia. She was admitted, and after 
several attempts I gave up all idea of returning the uterus. She told 
me, that for months before and during the whole time of her last preg- 
nancy the womb was external, and that the child was born while the 
entire uterus was beyond the vulva. She referred me for corroboration 
of these facts to a medical man at Greenwich, who had preserved notes 
of the delivery ; but from numerous daily engagements these notes were 
not applied for at the time. 

A corroborative case is related by Richerand in his Nosographie 
Chirurgicale, and by Capuron in his Mai. des Femmes, pa^es 300 
and 302. 

' A peasant girl, aged 14 years, made a violent effort during men- 
struation, which precipitated the womb externally ; it was not reduced, 
and she insensibly became accustomed to its inconveniences until the 
age of 22 years, when she married. She enjoyed excellent health, 
menstruated regularly, and bore the fatigues of severe agricultural 
labour. At the age of 40 she was childless ; at that period, however, 
< un jour son man dilata l'orifice uterine, y introduit le gland, et deter- 
mina la conception." The foetus and womb gradually developed, and 
the period of parturition arrived. The labour pains were regular, but 
insufficient to expel the foetus, as they were very imperfectly assisted 
by the action of the abdominal muscles and the pressure of the viscera, 
and more especially as the neck of the womb and the sides of its mouth 
had acquired a cartilaginous hardness. The contractions of the uterus 
at length became ineffective. M. Marrigues of Versailles was consulted ; 
he found the uterus external to the vulva, forming a tumour the size of 
a very large melon, whose parietes were hard, and its orifice placed 
25 



382 DISPLACEMENTS OF THE UTERUS. 

inferiorly, about an inch in diameter. A double incision was made to 
enlarge it. ; the labour terminated favourably ; a full grown dead infant 
was born ; and at the end of two months the woman had perfectly 

recovered. 

The following case occurred to Mr. Kingdon :— " He was requested, 
by a general practitioner, to visit a woman in labour, on whom it was 
supposed gastrotomy should be performed, in consequence of extra 
uterine pregnancy. The woman stated, that the cervix uteri had been 
external to "the vulva for two or three years, and had never returned, 
and that her husband had connexion with her through it. On making 
a vaginal examination, the linger passed readily into the mouth and 
neck of the womb, and left no doubt of their external position. The 
infant was very active, and its form was easily traced through what 
were considered to be the abdominal parietes. Dr. Blundell agreed as to 
the nature of the case ; but found the uterine orifice somewhat drawn up 
by the labour pains within the vulva. He also distinctly felt the infant's 
head. The labour, though tedious, was not violent, yet the woman 
gradually sank and died. On examination it was found, that only 
about two-thirds of the body of the womb had dilated to contain the 
fcetus, the parietes of which portion were not much thicker than brown 
paper. The lower third of the body passed, funnel-shaped, to the cer- 
vix, which was much elongated, with its sides softened and thickened, 
and sufficiently patent for the purpose which it had for a long time 
served." 

It is not often, even in the worst forms of procidentia and prolapsus, 
except during pregnancy, that the bladder or rectum are seriously im- 
peded in their functions, although strangury and irritation about the 
anus are then not uncommon. 

The vagina, which forms the external covering of the procident or- 
gan, is often ulcerated within a few weeks after exposure to the air and 
the acrimony of the discharges. These sores are seldom either exten- 
sive or deep, and are generally situated in or near the os uteri. Sir 
Charles Clarke says, correctly enough, that they have the appearance 
of healthy sores, and that they heal readily upon the replacement of the 
prolapsed parts. In this latter statement I do not concur, for few points 
in my hospital cases have been less easily effected than their cicatriza- 
tion. Certainly it is better when these ulcerations are not painful, and 
they are sometimes, to return the uterus first ; but, even with this 
advantage the discharges often increase, the ulcers enlarge, and great 
perplexity arises. It is rare for a completely procident uterus to involve 
the life of the sufferer in danger ; and few things excite more popular 
surprise, than that so important an organ should be entirely displaced, 
of enormous bulk in a state of ulceration, and yet without involving 
risk to life. Although this is true, it must not be forgotten, that serious 
evils are occasionally produced, especially when the procidentia occurs 
suddenly, after violent effort, or when pain and inflammation take place. 
I recollect once, during my apprenticeship at the Nottingham Hospital, 
to have seen a patient of Mr. Attenburrow's, in whom, owing to a fall 
from a corn stack, the uterus had been suddenly extruded from the 
vagina. It was of great size, deeply inflamed, and very painful. The 
pulse was quick and compressible. She was constantly sick, and 



DISPLACEMENTS OF THE UTERUS. 3S3 

gangrene seemed rapidly approaching. Spirituous fomentations and 
poultices, good nourishment, and brandy and ammonia, were most 
beneficially employed, and in a few days the uterus was replaced. 

Nauche has the following case (page 84, vol. i.):— "A lady, some- 
what advanced in life, who had long been the subject of prolapse, had 
suddenly induced, after a shaking drive, complete procidentia. M. 
Elmer found her suffering from pains in the stomach and limbs and 
exhaustion. The uterus was of enormous size, black, exhaled a fetid 
odour, and had all the indications of commencing gangrene. 

* In three days separation commenced, and soon afterwards the ute- 
rus was entirely detached. All the bad symptoms ceased, and her 
health was soon restored." 

Dr. Hamilton (Practical Observations, P. I., page 4) mentions the 
case of a poor woman of the name of Watkins, who died in Kensing- 
ton Work-house, in whom the protruded parts measured more than 
fifteen inches in circumference and six and a half in length ; it was 
found that they contained, besides the uterus, the urinary bladder, with 
a portion of the meatus urinarius, part of the rectum, the Fallopian 
tubes, and the small intestines. 

Capuron says, that the " cul-de-sac," formed behind the procident 
uterus and the vagina, often contains fluid. 

Diagnosis. — There is seldom much difficulty in recognising the ex- 
treme degrees of this displacement. The presence of the os uteri at 
the lower part of the tumour is almost infallible, although I have once 
known an ulcerated fissure in the base of a polypus, which I removed 
afterwards by ligature, not only mistaken for procidentia, but caustic 
was used for weeks, from the conviction that by this treatment it would 
be cured. Such errors may always be avoided by the introduction of 
a bougie into the opening; when, if it be the result of disease, the in- 
strument will soon be stopped in its progress ; if the contrary, it will 
probably pass to the fundus of the procident organ. It can never be 
difficult to distinguish procidentia from either partial or complete inver- 
sion of the womb, as in these latter diseases the os uteri will be want- 
ing, and the rougher, pale, mucous lining of the inside of the 
uterus, which, being inverted, forms the external covering, cannot 
easily be mistaken for the smooth", pink-coloured, and shining vagina, 
which conceals from view the procident uterus within. Nor in pro- 
cidentia will there be bleeding, a common and dangerous occurrence 
in inversion. 

_ Prolapse of the bladder, rectum, or vagina, and tumours of the pel- 
vis, can only through great inattention be mistaken for descent of the 
uterus. The greater elasticity and softness of the former organs, and 
the situation of the latter, and in all, the absence of the os uteri, lead 
to a certain diagnosis. 

Treatment.— Sir Charles Clark thinks, " if nothing were done in the 
way of treatment, a patient labouring under this disease might die 
from weakness, induced by the large discharges and the disordered 
state of the stomach ; or she might die from inflammation taking place 
in the parts contained in the inverted vagina, which are more liaMe to 
pressure than when in their usual place, the cavity of the pelvis and 



384 DISPLACEMENTS OF THE UTERUS. 

abdomen." My experience does not confirm this opinion ; for, neither 
in hospital nor in private practice have I ever seen death directly attri- 
butable to such a cause. I mention the circumstance, however, be- 
cause it marks the conviction of one of our most celebrated practi- 
tioners, who must have seen a great number of cases when he made 
the remark, of the serious character of the malady, of which he un- 
hesitatingly affirms, if fatal terminations are uncommon, " that it does 
frequently happen, that the patient drags on an uncomfortable life for 
a number of years, till she is destroyed by accident or by some other 
disease." 
' The treatment is of two kinds: — 

First. In relaxation and slight prolapse ; the recumbent posture, 
tonics, and astringent injections. 

Second. In the more aggravated forms of prolapsus, and almost inva- 
riably in procidentia, mechanical means, such as pessaries, or other 
contrivances for support. 

In relaxation and slight prolapse, the recumbent posture alone will 
often suffice, but there are few diseases in which the attendant symp- 
toms vary so much ; women sometimes suffer great misery from vaginal 
irritation, nausea, fever, and constipation, where there is only slight 
relaxation ; and in others the descent of the cervix only, so far as just 
to rest upon the perinseum, induces almost constant pressure, leucor- 
rhceal discharge, and strangury. Indeed, I have heard many patients 
declare, that the inconveniences of entire procidentia were far less than 
those of relaxation and prolapsus. Of delicate, susceptible women, 
this is especially true. Lisfranc erroneously affirms, that all the slighter 
cases of depression and prolapse are caused by congestion of the uterus; 
a statement excluding at once morbid capacity and relaxation of the 
vagina, which are, as most practitioners acknowledge, very common 
causes. The same author also states, more extraordinarily still (Mai. 
de PUterus, page 528), " that hitherto, even where the procidentia has 
been complete, he has avoided using mechanical support." " The 
congestion," he adds, " must first be treated, and if after that the dis- 
placement of the womb persists, the pessary may be employed, if the 
patient can bear it." That congestion of the uterus leads to displace- 
ment, is quite true, and so far M. Lisfranc is right ; but to affirm that 
the disease is always so induced, shows a want of judgment not uncom- 
mon in this writer. 

In cases where the patient complains of weight and pain low down 
behind the pubes ; of dragging of the bladder and rectum ; and an 
inability to stand long without great difficulty ; and especially where 
these symptoms are associated with amenorrhcea, it may be suspected, 
and it will often be ascertained on examination, that the uterus and its 
cervix are large, somewhat hard, and slightly tender ; in fact, in a state 
of congestion. Here it is that leeching or scarification of the neck, 
the recumbeut posture, the hot hip-bath, mild aperients, and regulated 
diet, are generally curative. Examples of congestive displacement 
are not uncommon where women have too early left their beds, or 
wherfc they have imprudently resumed their usual avocations too soon 
after confinement. On rest, indeed, too much stress cannot be laid, as 



DISPLACEMENTS OF THE UTERUS. 385 

[ believe few cases will receive even relief, where it is not practised. 
Dr. Hamilton was eccentric on this, as on many other points. He 
says, " that although the horizontal posture immediately relieves the 
uneasy feelings of the patient, the author long ago ascertained, that it 
tends not only to impair the general health, but also to aggravate the 
disease by increasing the relaxation of the natural supports of the 
womb.' : Of course all will allow, that a woman lying on her back 
for months, merely as an indulgence, would probably injure her health 
and induce obesity ; but the posture is here recommended that perma- 
nent as well as immediate relief of pressure, irritation, and nausea may 
be obtained. A few weeks, other remedies being employed, will 
suffice for this important purpose, so that the good will be gained with- 
out any injury to the general health. Nay, very frequently appetite, 
digestion, and alvine action will be improved by it. The Professor 
oddly enough also says, that taking off the weight of the uterus, already 
from congestion heavier than natural, and already stretching the uterine 
ligaments more than they can bear, from having sunk below its natural 
level, " increases the relaxation of these natural supports of the womb." 
How this can be I do not understand ; but certainly, correct observa- 
tion and common sense will satisfy any one, that the best way to restore 
tone and strength to a weakened, elastic cord, is to discontinue the 
action of the power by which it has been excessively stretched. This 
is precisely what is done by the recumbent posture. * 

The application of cold, either to the body generally, or to the pelvis 
and vagina, by salt water baths, either the shower, douche or hip-baths, 
and the use of astringent injections, are remedies whose value is authen- 
ticated by long practice. 

The efficacy of astringent vaginal injections cannot be denied, 
although their employment is still objected to by some, because they 
have produced mischief when improperly used. The abuse of a remedy 
is no argument against its judicious employment; and certainly few 
things have done more good, in this stage of the affection, than these 
injections. For directions as to their use and several formulae, I refer 
the reader to pages 108, 156, and 157. 

The alum hip-bath every nigh.t at 98°, and for fifteen or twenty 
minutes, is singularly efficient in giving tone and some degree of con- 
striction to the vagina. It should be of the strength of §xvj. of the salt 
to each gallon of water, and a bath of three gallons is usually enough. 
Immediately before and during menstruation these measures are to be 
suspended; and no judicious practitioner will ever use them, if there 
be either acute or chronic uterine inflammation or congestion ; or will 
neglect to adapt their strength to the peculiar irritability of the patient. 
Dr. Hamilton is vehement in his condemnation of this mode of treat- 
ment ; and his essays, notwithstanding their general excellence, exhibit 
in a strong light the disadvantages of an author writing under the un- 
alterable conviction, that he must be right and every one else in error. 
The advanced age at which he published these treatises, together with 
his manifest dislike of any contradiction, go far to explain their dicta- 
torial character. One out of many instances of his strong prejudice is 



3S6 DISPLACEMENTS OF THE UTERUS. 

seen in the following statement: "On the supposition that styptic 
injections' were safe, and that they could really restore tone to the vagina 
[which the author concedes for sake of argument, for the contrary is 
his sincere belief], it must be obvious, that if his view of the nature of 
the disease be correct, no benefit could accrue from the practice. Ac- 
cordingly, no practitioner trusts to these means in cases of any con- 
siderable degree of prolapsus uteri." On this passage it may be 
remarked, that styptic injections, judiciously used, are quite safe ; that 
the stronger astringents will really restore the vagina to its natural 
capacity, and must sometimes be left off, because they produce too 
much constriction ; and, lastly, that many practitioners employ and place 
great confidence in their efficacy. 

Again. " The author's experience has convinced him, that astringent 
injections into the vagina are apt to injure the uterus rather than the 
canal into which they are thrown ! ! He can solemnly aver, that of the 
numerous cases of chronic enlargement of the uterus which have fallen 
under his notice, by far the greater number had been unequivocally 
occasioned by the use of styptic injections per vaginam." When it is 
remembered how many women, suffering from uterine enlargement, 
neglect all remedies, till the weight, pain, and other inconveniences 
compel them to apply for relief ; how few use any injections effectually, 
the fluid scarcely ever reaching half-way up the vagina ; and that the 
popular astringents are green tea, zinc, and alum largely diluted — it 
will be difficult to regard as of any authority so partial and exaggerated 
a statement. 

Uterine, pelvic, and abdominal tumours may occasion prolapsus, not 
curable by the usual means. Relief may in such instances be given 
by a pessary ; but so long as the diseased growths exist, the prolapsus 
or procidentia, as one of the results, will be permanent. Thus, by the 
recumbent posture, tonics, and local astringents, the general health may 
be improved, and the natural capacity of the vagina restored, and still 
the prolapse will persist, or perhaps become worse. Such a result will 
render other means necessary. 

Treatment of Procidentia Uteri. — There will seldom be any difficulty 
in replacing a procident womb, if the attempt be made soon after the 
protrusion ; if the tumour be not unusually large and in a state of in- 
flammation ; or if there be no pelvic growths. Cases, however, do 
occur, where fomentations, leeches, and scarification are required in 
addition to general bleeding and antiphlogistic treatment ; and few 
things are more painful to the sufferer than a violent and forcible attempt 
to reduce an enlarged and inflamed womb. On one occasion, a fort- 
night elapsed before these measures had sufficiently reduced the size of 
the organ to permit a safe attempt at reposition : here, however, every 
circumstance was unfavourable ; the patient had long lived intempe- 
rately, carrying great loads on her head, and working very hard. The 
procidentia, too, which happened suddenly, was entirely disregarded 
for several days, till the severe pain, great weight, excessive discharge, 
and excoriation of the thighs, compelled her to seek advice. Leeches 
did good ; but I obtained far more advantage from scarification, and 



DISPLACEMENTS OF THE UTERUS. 387 

eventually she was able to wear a pessary constantly and comfortably. 
Dr. Labatt's case I append in a note, as it is both interesting and 
instructive.* 

It must not be supposed, when reduction has been effected, that the 
uterus can always be retained in the pelvis. In several hospital 

* Mrs. , aet. 27, suffered from prolapsus uteri after her first and second 

child. The uterus was returned, and retained, "in situ," by a pessary, which, 
however, was shortly afterwards withdrawn, as it occasioned " pain, strong bearing- 
down efforts, constant sickness at stomach, and a troublesome strangury." The 
uterus, after this, remained prolapsed for several months, and in kt March, 1806," 
says the Doctor, " I was requested to see her, when 1 found her worse in every 
respect ; she was much emaciated, and teased with a cough and copious night 
sweats. She had no appetite, but constant nausea and vomiting; the uterus pro- 
truded through the os externum to a great extent, it was considerably enlarged, 
and very sensible to the touch, and seemed evidently in a state of inflammation from 
friction between the thighs, which appeared excoriated by it. Around the os uteri 
was observed a superficial ulceration. The base of the tumour (which was of a coni- 
cal shape, the os uteri situated at the lower part or apex), formed by the prolapsed 
uterus, was surrounded by displaced intestine, and at the anterior part was discovered 
a swelling, which was found to be the bladder, as, on pressing it, the patient passed 
water involuntarily. The slightest attempt at reducing the uterus, considerably 
increased the lancinating pains through the pelvis, from which she was never entirely 
free. With these symptoms, she had a constant pain and sense of weight in the 
lumbar region, increased by an erect posture, a constant, and painful desire to pass 
urine, frequent and profuse uterine hemorrhage, and in the intervals a copious leu- 
corrhoea. The management of her family, in which necessity obliged her to take an 
active part, tended considerably to aggravate her uterine complaints. Her health 
became so bad, however, that for some time she was obliged to relinquish every kind 
of exercise, and remain in a horizontal posture. Under this untoward combination 
of circumstances, I expressed a wish to consult Doctor Clarke, who suggested scari- 
fication of the uterus, as the only remedy left untried, which afforded any probability 
of relief, at the same time adding that he recommended it on the authority of a Ger- 
man writer, never having seen it actually put in practice. He considered this pa- 
tient's situation so desperate, as to justify any rational expedient, however novel. 
She readily consented to the operation, which Mr. Dease performed, by making 
ten or twelve bold incisions in the form of radii from the apex of the tumour, as far 
towards the base as was consistent with the safety of the displaced intestine and 
bladder. The patient felt little pain during the operation. A discharge of blood, 
not, however, so copious as might have been expected, continued for several hours, 
followed by an ichorous discharge, which continued for some weeks. She felt no 
immediate change of any kind, nor any benefit from the scarification ; on the con- 
trary for five or six weeks she had reason to believe that it increased her distress; 
after that period, however, she was sensible of an amendment. The size and morbid 
sensibility of the womb began gradually to diminish, so that in a short time she was 
able to return it, and wear a pessary with little inconvenience, but this being too 
small, and falling: from the vagina, was discontinued. But at some distance from 
home, and anxiously engaged in attending her husband, who was dangerously ill, 
she allowed the uterus to come down, and remain so until the beginning of April, 
when she returned to Dublin. I found the womb completely prolapsed, but much 
diminished in size and not sore to the touch as formerly ; it was returned, and re- 
tained in its place by a pessary of proper size, which she now wears with little pain 
or inconvenience. The pains in her loins and through the pelvis are much better, 
the uterine discharges lessened, her general health improved, and she enjoys a degree 
of comfort to which, for many months, she was a total stranger. In August, 1S07, 
she was almost free from complaint, still wearing a globe pessary without incon- 
venience. Her general health was restored, and she could take long walks without 
any increase of her uterine complaints. — [Dublin Medical and Physical Essay*, vol. 
i., p. 235.] 



388 DISPLACEMENTS OF THE UTERUS. 

patients, I have been compelled to remove the pessary and allow the 
parts again to descend, to obviate pain, fulness, and inflammation. In 
one instance a patient named Berriman (there is a drawing of the 
disease in the Museum by Canton) left the ward, preferring the pro- 
cidentia to the sufferings attendant on reposition. For several years, I 
was in the habit of seeing her occasionally, and the organ continued 
procident till death, that event certainly having been hastened by con- 
stant and large leucorrhceal and menorrhagic discharges. The repo- 
sition may sometimes, in old cases, be maintained, by keeping the 
uterus in situ for several hours only, and then permitting descent ; a 
repetition of the experiment for a longer time eventually terminating in 
permanent reposition by means of the pessary. 

The reduction is best effected by placing the patient on her back, the 
pelvis being higher than the shoulders, to take off the weight of the 
abdominal viscera. The thumb and two or three of the fingers of one 
hand, or the palms of both hands, are now to embrace and make slight 
pressure on the lower part of the tumour, while the fingers are to knead 
the superior portion, and gradually to carry it upwards and backwards 
into the pelvis, and especially towards the hollow of the sacrum. The 
return being completed, a pessary must be introduced, so far as to rest 
on the perinaeum, thus affording the requisite support. Much, in such 
operations, depends on tact and gentleness: haste and violence are sure 
to injure, while address and patience are generally successful. 

Sometimes it is necessary to leech and foment the procident organ 
before it can be reduced ; and it is quite possible that some weeks may 
elapse ere the circumscribed ulcerations are sufficiently healed to allow 
the introduction and wearing of a pessary. In several instances, where 
the uterus has been of great size and extensively inflamed, a soft linen 
bandage, wetted with a warm solution of the Liq. Plumb. Subacet,, and 
applied sufficiently tight to impart a feeling of comfortable support, 
has contributed to an earlier reduction. The recumbent posture is in- 
dispensable, not only prior to, but for some days after the reposition, 
certainly till the pessary is adjusted and can be worn without incon- 
venience. The ergot of rye has been given in large doses, for the 
purpose of contracting the size of the uterus, and it is said with good 
effect ; although a practitioner, who had recently employed it, assured 
me, that the pain and spasm far outweighed any possible advantage it 
might have conferred. 

The ulcerations must be variously treated : in some very irritable and 
painful sores at Guy's, great good was derived from covering them with 
soft cotton wool, thus entirely excluding the action of the air. Caustic 
benefited many cases, and the powdered oxyde of zinc thickly applied 
over the surface, was every now and then curative. Sir Charles 
Clark's ointment, consisting of two drachms of Peruvian Balsam in 
one ounce of Spermaceti Cerate, is often exceedingly useful. Other 
ointments and lotions might be suggested, but they may be safely left 
to the knowledge and resources of the practitioner. 

Of the examples of irreducible procidentia, the majority are ob- 
noxious to ulceration, inflammation, and pain, evils generally curable, 
or susceptible of great alleviation ; but it sometimes happens that gan- 



DISPLACEMENTS OF THE UTERUS. 389 

grene and extensive subsequent sloughing render the removal of the 
displaced organ absolutely necessary. There are many published in- 
stances of the operation ; and in nearly all, for I am scarcely acquainted 
with a fatal result where the removal was judiciously managed, the 
patients have recovered well and quickly ; such results forming a re- 
markable contrast to the hazardous and formidable, but happily now 
obsolete, operation of extirpating the uterus from the pelvic cavity. 
Some years since I saw a surgeon remarkable for his promptitude, 
apply a piece of whipcord round the upper part of the sac of a proci- 
dent gangrenous uterus, and having carefully excluded the intestines, 
with one stroke of the knife he cut it off, about an inch below the 
ligature. The patient recovered without one bad symptom, but the 
ligature did not come away for nearly three weeks. Recamier and 
several English surgeons have performed the same operation. Wris- 
berg mentions a case of removal by a midwife with a knife ; Langen- 
beck extirpated the organ with a bistoury, and in a case where the 
ligature was used by Ruysch, the result proved fatal. 

Thus the procident uterus may be removed, either by the knife alone, 
by the ligature, or by excision, immediately after the ligature ; this 
combined method being probably the safest and most desirable. Of 
course the operator should be prepared, where the knife alone is used, 
to stop hemorrhage, either by pressure on the bleeding and incised sur- 
face, by tying the bleeding vessels, by caustic, and cold, or by the 
actual cautery. Such measures are, however, little likely to be re- 
quired where the combined operation by ligature and the knife has been 
employed. Great caution must be observed in excluding the intestines, 
omentum, or bladder from being injured in the operation. If the liga- 
ture be used alone, it should be passed round the pedicle of the tu- 
mour, and tightened daily, if there be not much pain. If, on the 
contrary, as I have several times known in the tying of polypi, the 
tightening produces severe suffering, then a longer time must elapse 
between the repetitions, and peritonitis must be guarded against. Here, 
too, care will be necessary to exclude the intestines from the grasp of 
the ligature. Several weeks are sometimes required for the comple- 
tion of the process ; and there have been instances, where patients 
have endured the evils of irritation, fetid discharge, and even inflam- 
mation for nearly two months. Hence Windsor and Duparcque, and 
Recamier also, have recommended amputation of the procident organ 
below the ligature, a few days after its application, by one stroke of 
the bistoury. This plan certainly combines the advantages of both 
operations, without the evils resulting from either if practised sepa- 
rately. 

Pessaries. — Few instruments have been so decried as the pessary, and 
yet, if judiciously used, it is by far the best mechanical support for a 
procident womb. It would indeed stand alone as a remedy, if it were 
universally applicable, or if its employment was never attended with 
inconvenience. But I can truly say, that during twenty-three years' 
practice, I have met with very few T instances, out of a great number, 
where it could not be introduced, or where its employment occasioned 
serious or permanent mischief. I do not, however, deny, that injury 



390 DISPLACEMENTS OF THE UTERUS. 

may have arisen from its having been injudiciously used ; from its 
having been of too large size, or of improper shape ; or from its having 
been too long worn without removal. Such errors may have led to 
ulceration, and to its passing into the rectum. Leucorrhcea may have 
been occasioned by it, although it must not be forgotten how commonly 
and excessively this secretion attends uterine displacement, where no 
pessary has been worn. DiefTenbach says, that he has frequently 
known the pessary occasion putrid discbarges from the vagina ; in some 
cases, dilatation to a most inconvenient extent ; in others, contraction 
of the same organ ; and, finally, in other females, dangerous cancerous 
or fungous productions from the vaginal mucous membrane. " Some- 
times," says the professor, "I was able to extract the foreign body 
with my fingers ; but in many other cases it was necessary to break it 
up with strong forceps, before the fragments of a stinking incrusted 
substance, whose composition could not easily be determined, were 
removed ; several patients laboured under excessive irritation of the 
bladder, and when the foreign body was large, many suffered for years 
under obstinate constipation^" It 'is evident that all these evils might 
have been avoided by the timely removal of the instrument. Putrid 
discharges certainly indicated the impropriety of its continuance ; and 
it is difficult to understand how dilatation of the vagina should have 
arisen, if the pessary had not exceeded the proper size. But certainly 
it is curious and satisfactory to find it urged as an objection, that the 
pessary induces contraction of this canal. Would that such a result were 
far more common, for then the instrument itself would be far more use- 
ful. Cancerous or fungous growths are attributed by Professor DiefTen- 
bach to the use of the pessary. Is this strictly true, or may not the 
statement have been unguardedly made ? That ulceration every now 
and then occurs, is acknowledged ; but certainly nothing like fungous or 
cancerous sores have ever fallen under my observation ; and if it could 
be proved that evils of such magnitude were induced, it would fully 
justify the abandonment of the instrument. The necessity for breaking 
up a pessary, and the difficulty of its removal, only prove that great 
neglect has occurred ; and show how incumbent it is on the practitioner 
or patient every few months to remove and wash, or to replace the old 
with a new pessary. I cannot forbear quoting the following remark of 
DiefTenbach: " On the other hand, however, it cannot be denied, that 
pessaries and the sponge are sometimes useful, when properly employed 
by a skilful hand." 

[It is evident from the above that the decriers of the pessary had 
used either cork, or gum elastic, or some other perishable substance. — 
Am. Ed.] 

The following is the operation by which he proposes to supersede the 
use of the pessary. I need scarcely say that in many, perhaps most of 
the examples of the malady, the remedy would be far worse than the 
disease. " After having emptied the bladder and rectum, I commenced 
by removing, from the left side of the vagina, a portion of the' mucous 
membrane, resembling in size and shape the section of a hen's-egg ; 
the small end of the ellipse being directed backwards, the oval end 
forwards and touching the nymphae. After having cleaned the edges 



DISPLACEMENTS OF THE UTERUS 391 

of the wound, I placed five strong stitches on either side in the follow- 
ing manner : — the two posterior sutures on each side were first applied, 
the uterus was then returned to its natural position, and the rest of the 
sutures were finished ; had they all been applied in the first instance, it 
would, perhaps, have been impossible to have returned the uterus after- 
wards. If we except burning pain in the vagina, and a moderate 
febrile movement, the symptoms which followed this operation were 
not very remarkable. The patient underwent an antiphlogistic treat- 
ment, and cold injections were thrown up every hour into the vagina. 
Some of the sutures were ultimately divided with the scissors, and 
some came away of themselves. The woman recovered, and the ope- 
ration was successful." The professor has repeated the operation 
many times since, w T ith equal success. Fewer ligatures were employed, 
generally three, but sometimes none at all, " for the edges of the wound 
frequently came in close contact with each other after the reposition of 
the uterus. ,: " In several cases, after having replaced the uterus, I 
have performed the operation by merely removing a fold of the vaginal 
wall, which was drawn forwards with Museux's forceps, and then clipped 
off. This is much the easier method of the two ; but the surgeon 
should always be on his guard against the danger of wounding the 
bladder or rectum, which might take place if a deep fold of the vaginal 
parietes was removed close to its base." — Lancet for May 20, 1837, 
p. 303. 

Another operation, the same in principle, but different as to mode, 
has been practised in this country at the suggestion of Dr. Marshall 
Hall. It consists in dissecting off a portion of the vaginal mucous 
membrane, and bringing the edges of the wound in contact by liga- 
tures ; so that when complete union takes place, the capacity of the 
vagina shall be reduced by the breadth of the portion removed. Dr. 
Heming says, the operation is easily performed : the patient being placed 
in the position for lithotomy, and the bladder being emptied, the uterus 
is to be drawn downwards, or to either side, according as it may be 
determined to take away the strip anteriorly or laterally. Dr. Hall had 
it removed from the anterior part of the tumour, while Dieflfenbach 
prefers taking off a portion from each side. The operation may be com- 
menced either from the upper end of the tumour, or from the os uteri; 
care being taken to remove as little as possible, besides the membrane 
itself, and especially to avoid wounding the bladder. The three liga- 
tures, for this number will generally suffice, should all be inserted be- 
fore any one of them is tied ; that nearest the os uteri should be drawn 
first. While the tying is going on, the tumours should be pressed up- 
wards, so that when the operation is finished, the tumour should be 
quite within the cavity of the pelvis. It is recommended that the strip 
should be triangular, and its apex towards the os uteri. There is sel- 
dom much bleeding, but if necessary, the divided vessels may be 
twisted, or cold may be applied. Pain is rarely felt, except when the 
part about the os externum is removed. DiefTenbach remarks, that 
occasionally the patient suffers from vaginal heat, pain and discharge ; 
and vaginitis may require the removal of the ligatures and antiphlogis- 
tic treatment. 



392 DISPLACEMENTS OF THE UTERUS. 

The testimony in favour of these surgical means of relief is pretty 
unanimous so far as the operators themselves are concerned, but yet 
without any diminution in the number of the cases, in which such surgical 
means might be tried, we scarcely hear of a repeated operation. This 
probably arises from the disproportionate severity of the remedy ; for, 
independently of a natural aversion to the surgeon's knife^ excepting 
in cases of real and dangerous necessity, it seems scarcely reasonable 
that a woman should submit to such measures when nearly permanent 
relief may be afforded by safer and less painful means. I have seen 
many and really bad examples of procidentia, and yet in no single in- 
stance have I felt justified in recommending these operations. DiefFen- 
bach, Ireland, Hall, and Fricke speak in high terms of their success. 
One case was shown me by the operator himself; but although the 
operation had been ably performed, the uterus was again making its 
way through the external parts. Dr. Davis objects u to the practice 
forchild-bearing women, inasmuch as any considerable contractedness of 
the vagina, which the abstraction of a large portion of its substance might 
be expected to produce, and which, in practice, it might not prove an 
easy thing to confine within any assignable limits, could not fail to ren- 
der labour difficult and even dangerous." I concur in this opinion, not 
from actual experience of the results of the operation itself, but from 
what I have observed after ulcerations of the vagina, the consequence 
of undue force in delivery, and in the use of forceps, as also after sur- 
gical operations. In such instances a predisposition to increased con- 
traction has often been observed, and w T e all know how anxious are 
the labours where cicatrices, bridles of indurated tissue, and hardness 
about the vagina, obstruct the natural progress of parturition. These 
remarks are not applicable to unmarried women, or to any in whom 
the catamenial function has ceased. Of course all operation should be 
avoided if there be any development, however slight, of scirrhous or 
cancerous disease ; and even where this diathesis is known or strongly 
suspected to exist, it would be imprudent to run the risk of exciting it 
into activity by incisions about the vagina and uterus. Dr. Fricke, 
the most zealous pursuer of the method, relates an instance of episo- 
raphie, " where the patient afterwards became pregnant, and was de- 
livered by the forceps without the artificial bridge giving way." It 
would have been more satisfactory still, if Dr. F. could have told us, 
that " this artificial bridge" had not at first been produced by operation 
itself. 

Various other means have been unsuccessfully tried to procure ad- 
hesion of a portion of the opposite surfaces of the vagina, procuring in 
this way, at the cost of destroying the functions of this important organ, 
a cure of the disease. Irritating cerates and a bag of alum, did, in Dr. 
Hamilton's practice, occasion " inflammation and sloughing, but no 
adhesion took place. These experiments having failed, the sides of 
the vagina were brought together by ligatures. -. The operation was 
ably performed by Mr. Liston, but no union was effected, and the suf- 
ferings of the patient were such, that the author resolved never again 
to be a party to such a practice." All must applaud the professor's 
resolve, for certainly measures followed by inflammation and slough of 



DISPLACEMENTS OF THE UTERUS. 393 

the vagina, and surgical operations entirely useless, but so severe as to 
occasion intense suffering, were sadly disproportionate to a malady sus- 
ceptible of such great alleviation by other means. Caustic and the 
actual cautery have both been tried, but without success. 

These, then, are the processes by which it has been attempted to 
obtain a radical cure of procidentia, and to dispense with the use of 
pessaries and all other artificial supports. I leave the reader to form 
his own judgment of their safety or danger ; and without any prejudiced 
declaration that they are always useless, it may be said, that the cases 
are few indeed where such methods are justifiable, compared with 
those in which well-adjusted pessaries will effectually relieve, and not 
unfrequently cure the disease. 

Before describing the various kinds of pessaries, it may be well to 
dispose of the objections urged against the instrument, by Dr. Hamilton 
and other writers. It is affirmed, that pessaries can only act as pallia- 
tives ; that they cause irritation and leucorrhcea ; that they make inju- 
rious pressure on the contents of the pelvis ; that if not frequently re- 
moved, they become incrusted with a calcareous matter, which may 
lead to ulceration even into the rectum, putrid discharges, and fungous 
and malignant growths ; that patients, while wearing them, have suffered 
from irritation of the bladder and protracted constipation; and that cases 
from time to time occur, where, from the laceration of the perineeum, no 
ordinary pessary can be retained ; and, lastly, that they subject the pa- 
tient to the charge of the medical attendant for life. 

It is not true, that pessaries never act but as palliatives. I have 
known many instances of their employment for several months, no other 
treatment having been resorted to, where a perfect cure has been ob- 
tained ; so perfect, indeed, that on removing the pessary, the descent has 
not again taken place. But if this objection were allowed, it would de- 
tract but little from its value, as the recumbent posture, astringent in- 
jections, tonics and cold, are far more efficacious with than without the 
pessary. Irritation and leucorrhcea may be produced, and I know there 
are patients, who, on these accounts, cannot wear it ; but how few are 
these compared to the number where such evils subside in a few days, 
if the pessary has been accurately selected as to size. I have often, 
indeed, heard the remark, that so far from there being annoyance, there 
has scarcely been any consciousness of the presence of the artificial 
support. That ulceration into the rectum, although probably not more 
than one such instance ever occurred, may have been occasioned by 
too large a pessary, or by its incrustation, cannot be denied. But how 
easily might such evils have been prevented ? Surely if these danger- 
ous consequences are not inevitable, they cannot be adduced against 
the judicious employment of the remedy. On one occasion at Guy's, 
I had some trouble in taking away a caoutchouc pessary, which had 
become hard from the calcareous deposit of eight or nine years, it never 
having been removed during the whole of that time; but on my making 
some severe remark to the woman on her neglect, she simply replied, 
that the comfort she had derived for the years she had worn it, far out- 
weighed any suffering she had latterly endured. She w T ent out of the 
hospital quite recovered in a few weeks, and never afterwards, at least 



394 DISPLACEMENTS OF THE UTERUS. 

to ray knowledge, had a return of the procidentia. I scarcely know 
any cases where irritation of the bladder, strangury, or constipation 
have continued beyond the first fortnight after introduction, if exces- 
sive exertion and errors of diet have been avoided. There are ex- 
amples where, after replacing the parts and introducing a pessary, ex- 
citement, pain, and fever run so high, that abdominal inflammation may 
be feared. In such, probably, the mischief is more consequent on the 
reposition than on the pessary ; but be this as it may, the instrument 
should be removed, and the uterus permitted again to come down. 
Bleeding from the arm, fomentations and poultices, leeches to the ab- 
domen, and purging may be required, and for some days or weeks the 
attempt ought not to be repeated. If the pulse again rises, and the 
same evils are threatened, the reposition will be frustrated, and such a 
case may be one in which the uterus must remain procident. Lacera- 
tion of the perinaeum certainly prevents the beneficial employment of 
the common pessary ; but I cannot conceive w-hy such an exception 
should be taken. These lacerations are happily exceedingly rare; — as 
compared with procidentia of the uterus the proportion must be small 
indeed ; and it certainly cannot be fairly objected to any instrument, 
that it is not applicable to cases for which it w r as not designed. The 
circular ring pessary, the one in most general use, was intended to rest 
on the flooring of the vagina. Without such a foundation it cannot be 
employed, and this very flooring is often entirely destroyed by laceration 
of the perinaeum. 

Dr. Hamilton, lastly, asserts, " that pessaries subject the patient to 
the charge of the medical attendant for life." Is not this contradicted 
by every day's experience? Women take out, wash, and replace the 
pessary themselves. I have known many who do this, and who only 
apply to their medical attendant in some unusual emergency, or when 
they think the size of the support requires diminution. The pessary is 
certainly not a perfect instrument ; but how rarely, in the treatment of 
disease, have we the choice of remedies so good as to be without some 
imperfections ? Does it not much more frequently happen that our 
choice is limited ? Procidentia is an evil, the wearing of a pessary is 
an evil also ; but it does not require any great discrimination to per- 
ceive, or candour to acknowledge, that the greater evil by far is the 
procidentia ; and that the lesser evils of the pessary are merged in the 
benefits it so constantly confers. 

A good pessary should be light, hard and smooth, and so accurately 
adapted to the size of the vagina, that whilst it supports the uterus, it 
should produce neither pressure nor abrasion, and certainly not inter- 
rupt the evacuation of the bladder or rectum. 

To fulfil these conditions, the ingenuity of medical men has been 
largely taxed, and many pages would be required for a summary only 
of their various inventions. Gold, silver, lead, iron, sponge, cork, 
elastic gum and boxwood have all been used. The last is by far the 
best material, as it is light, and yet of hard texture, and so close in its 
grain, that it is not acted on by the discharges ; being also, when well 
polished, perfectly smooth. 

[Here, again, we are astonished that Mr. Ashwell has omitted the 



DISPLACEMENTS OF THE UTERUS. 395 

most common pessary in the United States, and by far the cleanest and 
best ; namely, that made of glass. — Am. Ed.] 

The circular boxwood, or ring pessary, is that in most common use. 
Its edges are round and smooth, with a central aperture for the tip of 
the finger to alter its position, or to assist in its removal, and to permit 
the escape of any natural or morbid discharges. In the construction of 
this form, care should be taken that the outer margin is tolerably thick, 
by which better support is afforded to the uterus, and there is less risk 
of any injurious pressure or abrasion of the inner surface of the vagina. 
It is also of still greater importance, that the central hole be not too 
large. A small aperture will suffice for the purposes already mentioned, 
a larger one will allow the entrance and strangulation of the os and 
cervix, an accident exceedingly painful to the patient and perplexing to 
the practitioner. In a case lately, I had to scarify freely before the 
cervix could be set at liberty. It* is probable, that many of the cases 
of inflammation, ulceration, and gangrene have had such an origin. 
But this could never happen, if, instead of an aperture large enough for 
the thumb, as it often is, there be one so small as to admit only the tip 
of the forefinger. Laundy has for many years made all the pessaries 
used at Guy's on this principle. It is rare to hear any complaints of 
this pessary when it has been of right size and properly introduced, for 
although I have tried every kind of abdomino-uterine supporter, Hamil- 
ton's, Hull's, and several others, yet I find that patients give the pre- 
ference to this simple, cheaper, and generally more efficient support. 
The perineal pad, the distinguishing feature of these more elaborate 
contrivances, is not without its disadvantages. I have one patient who 
never has the bowels relieved without removing the " supporter ;" and 
latterly, she has discontinued it altogether, because it produced great 
irritation and pressure about the vulva and rectum. This lady now 
wears a common circular boxwood pessary. Women, who can them- 
selves remove and re-introduce this support, ought to be supplied with 
some of the same and of lesser size, never using a pessary a second 
time. If the assistance of a medical man is required, once in three, 
four or six months will suffice, although, of course, exigencies may arise 
rendering more frequent attention necessary. Occasionally these in- 
struments are worn for twelve or eighteen months without removal; and 
some months since I took one away which I had introduced four years 
previously. The patient had been in Van Diemen's Land during the 
interval, and had derived the greatest comfort from the support thus 
afforded. The uterus was so high up, and the vagina so healthy, that 
she has since gone through her daily duties without the pessary, and 
without any further descent. For married women this form is the best, 
as neither intercourse nor conception are prevented. Let it also be 
understood, that other remedial measures are not to be given up, as the 
time during which a pessary may be necessary, will much depend on 
the patient's persevering in the recumbent posture, and the use of 
astringent injections. 

But there are cases where, owing to the morbid capacity of the 
vagina, the hollow ball pessary must be used. This form also is best 
made of boxwood, with several holes for the escape of the discharges, 



396 DISPLACEMENTS OF THE UTERUS. 

and having affixed to one end a slip of tape to facilitate its removal. 
Often this will be retained, when of proper size and well introduced, 
without any external mechanical contrivance ; but where the dilatation 
of the parts is excessive, the plan of Sir Charles Clark has succeeded 
well. But most surgeons are somewhat ingenious, and I frequently see 
inventions of greater or less utility, the half of which it would be im- 
possible to enumerate. 

Clarke retains a globular pessary u in situ" in cases where the dila- 
tation of the parts is excessive, in the following way: — " In the first 
place, a pessary is to be chosen, of the size which the case requires, 
and a small slip*of brass is to be attached to it by its two ends, leaving 
a space between the instrument and the centre of this piece of brass : a 
belt of leather, long enough to go round the patient's body, is also to 
be prepared ; to the centre of which, behind a brass wire, as thick as 
a common quill, is to be attached a screw. This wire is now to be 
properly bent, and the pessary being introduced into the vagina, the 
wire is to be passed between the pessary and the piece of brass at- 
tached to it ; and being brought up between the thighs, it is fixed to 
the fore-part of the circular strap. The reduced parts are by this means 
supported by a pessary, and this is kept in its place by the unyielding 
piece of metal." 

In still worse cases, where for instance the perineeum has been 
lacerated, stem pessaries of different shapes, and variously arranged, 
have been used ; but it seems hardly necessary to occupy space by an 
elaborate description, as in every surgical instrument maker's shop a 
great number may always be seen. 

The sponge pessary remains to be noticed. I know only of one case 
in which it should be used — where there is excessive irritation and 
tenderness of the vagina and os externum. Here it may probably do 
good, if removed often enough to prevent abrasion or soreness. The 
objections to sponge are its increase of size, and consequent dilatation 
of the vagina, and its imbibing and retaining the discharges. 

Dr. Hull employs an apparatus, the distinguishing feature of which 
is the keeping "in situ" of the procident organ by external pressure. 
A pad, elastic but firm, is made to bear upon the perineeum, without in- 
terfering either with the rectum or vulva, a belt round the waist, and a 
connecting strap passing from before to behind, aided by springs and 
hooks, securing sufficiently firm compression to prevent the descent of 
the replaced womb. Several of my patients have worn this pad com- 
fortably and with tolerable success ; but in most cases the pressure has 
induced pain, heat, and leucorrhcea, and they have gladly exchanged 
it for the pessary. [Mr. Ashwell might have added, that much advan- 
tage would be derived from the external support derived from the ante- 
rior or abdominal pad, omitting the perineal support altogether. Several 
cases have presented themselves to my notice, in which the upper part 
of Hull's or some similar instrument alone succeeded in relieving the pa- 
tient, and this must be attributed to the support afforded to the super-in- 
cumbent viscera. There is a much better supporter than Hull's in com- 
mon use now in Philadelphia, consisting of an abdominal pad and two 



DISPLACEMENTS OF THE UTERUS. 397 

springs, one on each side, terminating in a smaller pad behind, the 
perineal pad may be added or omitted at pleasure.— Am. Ed.] The 
expense of these more elaborate instruments, is to poor women, in 
whom the disease is most common, a serious matter, especially as 
they frequently want repair. On the whole, I regard the pessary as 
by far the most applicable, and generally the most efficient remedy for 
procidentia.* 

This chapter would be incomplete, if allusion were not made to 
elongation of the cervix uteri, a morbid alteration of form of the organ, 
exceedingly likely to be mistaken for prolapsus. I have seen two well- 
marked cases. One was a patient of mine in Guy's, and had borne 
several children. After the last labour, the uterus continued much 
lower down than usual, and marital intercourse was difficult and pain- 
ful. Scarcely any attention was paid to it for many months ; but on her 
admission, I was satisfied that the fundus and body of the womb were 
healthy and in their natural position, and that all the symptoms de- 
pended on elongation of the neck. The os was nearly external, and 
of considerable breadth ; the rimae were thin and expanded ; and the 
flattened and attenuated cervix was easily traced to the upper part of 
the vagina, this canal being broad and dilatable :— the length of the 
cervix was four inches. 

A medical friend gave me a rough drawing of a case of this kind 
lately under his care, where the cervix was drawn out nearly three 
inches, terminating in a very small and circular os. 

In Guy's Museum we have a preparation showing the body and fun- 
dus quite healthy in structure, and normal in form and position ; but 
the cervix is flattened, and of great length, and must probably during 
life have descended considerably below the external parts. 

Dr. Heming described an example, in the Medical and Physical 
Journal, Vol. 68, for August, 1832, " there was also hernia of the pos- 
terior part of the vagina ; the descent of the intestine in the utero-rectal 
fold of the peritoneum had carried down the os uteri, the uterus itself 
not being displaced, and its cervix consequently elongated mechani- 
cally ; and this I think the usual cause of this form of uterine disease." 
Boivin alludes to the affection, and says, "in some cases we have 
seen the whole organ drawn out as it were into a cord." 

Lallemand saw examples of it in advanced age ; and Leroux of 
Dijon observed something like it, but only during pregnancy. " In 
some cases," he said, " it is only the anterior labium of the os tinea? 
that is elongated ; in others, it is the entire cervix. I have found it 
projecting from the os externum, like the neck of a bottle with its rim. 
I introduced my finger into the opening, as far as the internal orifice, 
which was elosed by the membranes of the ovum. As soon as the 
pains of labour came on, the cervix became shorter, and was gradually 
obliterated in proportion as the interior orifice expanded." 

In a case of elongation similar to that of Leroux, only in the unim- 

* Baudelocque makes this remark, "A sensation of weakness, lowness, and faint- 
ness supervenes, if the uterus descends low down, and the woman insensibly falls 
into a marasmus, if some remedy be not applied. I have seen several, in whom the 
return of health and flesh has been produced merely by the application of a pessary." 
26 



398 DISPLACEMENTS OF THE UTERUS. 

pregnated state, the surgeon, mistaking it for polypus, notwithstanding 
the presence of the os uteri at the extremity, applied a ligature, and the 
patient died of peritonitis. 

A pessary could hardly be available here ; its pressure indeed would 
be painful, if it kept up the cervix from below, which, if possible, could 
not be done without great danger of inflammation. The removal of 
this morbid elongation, still leaving the passage to the uterus free, 
affords unhappily the only means of relief; and even this could not be 
recommended, excepting the patient were married and desirous to have 
children. In women in whom the catamenial function has ceased, 
neither an operation nor artificial support should be attempted. 



INVERiSIO UTERI. 

History, Causes, and Symptoms. — Inversion of the womb is a widely 
different malady from procidentia ; for, while the organ is equally de- 
pressed in both, in the former, the uterus is turned inside out ; the 
fundus losing its position, and sinking perpendicularly inwards and 
downwards, till it passes through the os, forming a tumour between the 
thighs. The sac is lined with peritoneum, being an extension of the 
abdominal cavity, w T hile the external covering of the tumour is the 
mucous membrane of the uterus. It is scarcely necessary to remark, 
that the ovaries, Fallopian tubes, and intestines, will occupy the space 
formerly filled by the now inverted womb. 

Inversion is the most dangerous of the uterine displacements, but 
happily the most rare. In many years' private and consultation prac- 
tice, I have only met with it twice ; and in more than eight thousand 
labours occurring at the Lying-in Institution of Guy's Hospital, we have 
not had a single example. The obstetric patients in Petersham Ward 
have, during the last thirteen years, exceeded eight hundred ; and yet, 
neither amongst them, nor in the far greater number of the obstetric 
out-patients, has there been one case, either of recent or chronic 
inversion. 

It occurs most frequently immediately or soon after labour, the re- 
laxed state of the puerperal womb being a favourable condition. A 
polypus occasionally, where the uterus has been large, has dragged 
down and inverted it; and it is perhaps possible, that the virgin 
womb might become the subject of inversion, if its parietes had been 
extended and weakened by accumulation of the catamenia, water, 
or pus. 

There are three degrees of the disease. 

Depression, where the fundus uteri sinks in the form of a cup within 
the cavity, but does not descend far enough to form a tumour in the 
vagina. Here the diagnosis is difficult ; and in the case of a polypus, 
except the abdominal integuments were so thin, that the depression of 
the fundus could be felt through them, it would be impossible. If, 
however, such a degree of inversion was suspected in the puerperal 
womb, the introduction of the finger or hand into the uterus would lead 
to a correct opinion. 



DISPLACEMENTS OF THE UTERUS. 399 

Partial inversion is the second degree, and implies that the uterus 
has descended, as in prolapsus, into the vagina, but not beyond the os 
externum. Here the depression of the fundus, and the partial absence 
of the uterus from the hypogastric region will be such, especially after 
delivery, as to leave no doubt ;— the vaginal tumour being large, semi- 
spherical, nnd closely grasped by the os uteri. 

In complete inversion the womb not only fills the vagina, but pro- 
jects beyond it, forming, if in the puerperal state, a large tumour, with 
the os uteri above, the fundus below, and the internal membrane cover- 
ing it externally. In this, the worst form, the vagina partakes of the 
inversion. 

Most authors have divided the examples of this formidable malady 
into acute or recent, and chronic: while, with greater practical accu- 
racy, an able writer, Dr. Radford of Manchester, has substituted the 
terms " reducible" and " irreducible." In the former class may gene- 
rally be placed the recent, and in the latter, the chronic cases of the 
disease. 

Of the causes some are intelligible enough. Hard or sudden traction 
on the umbilical cord, during a relaxed condition of the uterus, and a 
violent pulling away of the placenta by the hand before it is entirely 
separated, require no explanation. Dr. Davis dwells almost exclusively 
on a short cord, or the coiling of it around the neck of the child, as the 
great causes, but he is probably in error, as we do not find that inver- 
sion has followed in these cases, and in both the instances of the dis- 
ease which I have seen, the funis was of the usual length. There must 
be other causes beyond these mechanical ones ; for the accident occurs 
spontaneously, and after labours where there have been neither severity 
of pains nor delay. In one of my cases there seemed to have been 
almost instantaneous relaxation following contraction ; the patient com- 
plained suddenly of pain and that another child was coming, and the 
uterus was inverted and protruded in a moment. 

There is, probably, prior to the inversion, a great change in the 
uterus ; either sudden and violent contraction, or instantaneous and 
complete relaxation ; or the first maybe immediately succeeded by the 
latter state. Some patients complain, just before the occurrence, of 
severe pain, and they fancy there is a second child ; an idea strength- 
ened by the pressure and fulness of the vagina, as the inverting womb 
is passing through it. In Case 83, the event was preceded by pain, 
followed by sudden and complete sinking of the womb ; she felt as 
though " the whole inside was dropping through the external parts." 

Dr. Radford remarks, "that the' uterine pain, diminution of bulk, 
firm resisting feel, sudden formation, and rapid protrusion, warrant him 
in the deduction, that the fundus and body of the uterus, so far from 
being in a state of collapse or relaxation, are really in a state of unna- 
tural excitement and action. But this is not the case with the os uteri; 
on the contrary, it is soft and yielding, as we find that it offers no re- 
sistance to the coming down of the tumour, whose protrusion is forcible 
and rapid." 

^ It may then be inferred, that a quick labour, or any circumstance 
disturbing the natural progress of parturition, and inducing irregular 



400 DISPLACEMENTS OF THE UTERUS. 

and sudden contractions — the forcible use of instruments, mental ex- 
citement and alarm, and hemorrhage resulting from attempts to remove 
the placenta, may all of them be regarded as so many causes of in- 
version. 

Capuron says, that dilatation of the os uteri, and atony, and flaccidity 
of the uterine parietes, are the predisposing causes. The exciting 
causes are weight of the fundus, violent expulsive efforts, tractions by 
the funis, and the dragging of a polypus. 

From the two cases I have seen, I have little hesitation in believing, 
as I have before observed, that the most general condition of the puer- 
peral womb, immediately preceding inversion, is one of combined con- 
traction and relaxation. Thus, while the fundus and a portion of the 
body of the organ are contracted, the cervix, and especially the os, are 
decidedly relaxed ; affording the utmost facility for the spontaneous 
descent and inversion of the heavier and contracted fundus. Thus we 
may understand, that pulling at the cord, or withdrawing the hand 
from the uterine cavity, with the placenta only partially separated, and 
a short funis, are by no means the sole causes of inversion. I do not 
mean to deny that the uterus may be thus inverted ; but when it is 
remembered how often the funis has been short and the labour quick ; 
how many cases are recorded, several of which I have myself seen, 
where the child was precipitated, and the cord suddenly snapped ; how 
often hasty practitioners and ignorant midwives have detached it from 
the placenta, and yet without inversion — it may not be improperly 
assumed, that this fearful accident has been by far too universally attri- 
buted to mechanical violence. Perhaps a cause more explanatory may 
be found in the operation of some concealed and ill-understood influence 
on the uterus itself immediately after labour, by which its functions shall 
be so deranged, that contraction and relaxation of different portions of 
its structure shall simultaneously occur. 

It is scarcely necessary to urge the importance of vaginal examina- 
tion, if there be a suspicion only of the accident. It may not be easy 
to ascertain its precise extent if the inversion be incomplete ; but if 
there be hemorrhage, faintness, and fulness of the vagina, and no uterus 
to be felt above the pubes, there need be no doubt. Where the inver- 
sion is complete, the tumour will generally be larger than the uterus at 
the same time if it were in the pelvic cavity ; as it contains very fre- 
quently portions of intestine, and the ovaries. Madame Boivin says, 
that in a case published by Stalpart Vanderwiel, the intestines were 
laid bare after death by an incision of the tumour, still in its situation 
between the femora. Baudelocque has given a case somewhat similar, 
and Ruysch has figured a tumour, the volume of which is six inches 
in all directions. We learn from Levret, u that the sac formed by the 
inverted uterus and vagina, in the case of a person seventy years of 
age, was filled with a portion of the rectum, of the bladder, and of the 
small intestines, and with the Fallopian tubes and ovaria." — (Diseases 
of the Uterus, p. 114.) 

The symptoms attendant on recent inversion are much more danger- 
ous than where the disease has existed long, although irreducible. 
The most alarming symptom is exhaustion, portending immediate dis- 



DISPLACEMENTS OF THE UTERUS. 401 

solution; resembling very closely the frightful sinking following lacera- 
tion. It cannot always be attributed to hemorrhage, as it very frequently 
occurs before there has been any flooding. In one of my cases the 
countenance was sunken and deathly ; there was cold perspiration, a 
fluttering pulse, and vomiting, but no hemorrhage. Convulsions have 
been enumerated amongst the consequences by Siebold, although it is 
not improbable that the jactitation of approaching death might have led 
to the opinion. Of course the symptoms are not always equally alarm- 
ing; the inversion may not be complete ; or the patient may belong to 
that class who are not easily affected even by the gravest accidents. 
Hemorrhage is very dangerous, and Mr. Newnham says (Essay on In- 
version, p. 86), "when the uterus has become inverted, immediate 
hemorrhage takes place, which is quickly followed by faintness, and a 
sense of fulness of the vagina, and, in the greater number of instances, 
almost by immediate dissolution." In neither of my cases was there 
any flooding, but the exhaustion was great in both. 

Terminations. — Where inversion is not early discovered and replaced, 
it generally proves fatal in one of two ways. Either the patient sinks 
suddenly from syncope and exhaustion, with or without hemorrhage ; 
or, having escaped these more immediate dangers, she lives for a 
longer 'or a shorter time in great misery, the subject of constant irrita- 
tion, frequent pain, and profuse mucous, purulent, or sanguineous dis- 
charges. There are, however, results more favourable than these ; but 
they can only be regarded as rare exceptions to a general rule. 
Churchill says, " that if the patient do not sink from the primary shock, 
and if no destructive process takes place in the tumour, it will, after a 
while, shrink very much in size, and the patient may suffer compara- 
tively very little annoyance ;" Lamotte (p. 383) mentions a woman 
who had inversion for more than thirty years ; and Burns (p. 486) refers 
to a case by Dr. Cleghorn, " where the uterus slowly returned to its 
natural size. During twenty years this woman menstruated, and 
enjoyed tolerable health. The womb was smooth, moist, and only 
slightly painful." I believe there are no cases on record, at least I 
have been unable to find any, where the inverted organ has been 
attacked by malignant ulceration. It has been regarded as possible, 
that after many years' continuance, the disease might be spontaneously 
cured ; and Dailliez has ingeniously attempted to explain this by sup- 
posing, that the Fallopian tubes gradually pull up the detruded womb. 
One of his two cases is sanctioned by the authority of Baudelocque, 
and here the restoration occurred after eight years. It is difficult to 
accept such an explanation. Burns says, " if it be physically possible, 
it must at least be exceedingly rare." 

It must not be supposed that hemorrhage is always present. In my 
two cases there was no flooding ; and in Dr. Radford's five or six there 
was scarcely any, and in others which might be adduced, the syncope 
and collapse were not the result of the loss of blood. 

I have never had an opportunity of watching a case of chronic in- 
version ; but I can easily imagine that Clarke is right in saying, that its 
sensibility will gradually diminish in consequence of the formation of a 
kind of epithelium on its surface ; nor is it at all improbable, " after 



402 DISPLACEMENTS OF THE UTERUS. 

recovery from the state of exhaustion or nervous depression into which 
the patient was at first thrown, that the repeated hemorrhages and con- 
stant leucorrhoea will render her countenance pale and exsanguined, 
and subject her to various secondary symptoms, such as syncope, 
dropsical effusions, hectic, &c." 

The following inferences may be drawn from what has been ad- 
duced: — 

1. Although the uterus, when developed by pregnancy, has been 
frequently inverted by traction on the cord, or by sudden and forcible 
attempts to take away the placenta ; yet, almost as frequently the 
inversion has occurred spontaneously, entirely independently of any 
mechanical cause.* 

* My own Cases, Nos 8.3, 84 and 85, one by Dr. Waller, Denman's Midwifery, p. 
424, several of Dr. Radford's, Mr. Barker's in the Medical Gazette, April 5, 1844, 
and probably many others, confirm the fact of spontaneous inversion. 

In Dr. Radford's (Case 1), Mr. Wood saw the patient two hours after delivery, very 
much exhausted, with pallid countenance, and a cold surface. Upon examination, 
he found a large tumour (the inverted uterus), with the placenta attached. There 
was neither hemorrhage nor convulsions, and the midwife assured him, she had made 
no effort to remove the placenta. Mr. Wood detached it, and then without difficulty 
reduced the uterus. The patient recovered well. 

In Case 2, managed by Mr. Mann, the patient was suddenly seized, ten minutes 
after the birth of the child, with violent bearing-down pain, and on ocular investiga- 
tion, the uterus was found to be inverted, having passed externally from the vagina 
with the placenta attached to it. In this instance the inversion was entirely sponta- 
neous, as ih'e funis had not been touched at the time it happened. The placenta was 
peeled off prior to the re-inversion. After carrying the womb through the os uteri, 
it suddenly started from the hand, as a piece of India rubber would, under similar 
circumstances. There was no hemorrhage, and the reduction was effected in a few 
seconds; but still the state of the patient was most alarming. The face became 
suddenly pale, and bedewed with a cold sweat; the pulse was rapid and unsteady ; 
there was great prostration of strength, and a threatening of convulsions and death. 
Brandy and laudanum, hot flannels and friction restored her. She did weil, and has 
since borne children. 

Case 3, was one also of spontaneous inversion. The labour was propitious, and 
the placenta was naturally detached and expelled. There was no hemorrhage; but 
in 48 hours after parturition, when, being called by the midwife, Dr. Radford exa- 
mined, he found a tumour of considerable size, passing partly through the os externum; 
it was bard and resistent, externally it felt flaky, and was broader below than above. 
The os uteri was difficultly reached, and it tightly embraced the upper part of the 
tumour. Attempts for two hours were made unsuccessfully to re-invert it. The 
health declined, and there were symptoms of peritonitis and retention of urine. After 
the subsidence of these symptoms, another, and an unsuccessful effort was made to 
reduce the tumour. She now suffered from sanguineous, purulent, and mucous va- 
ginal discharges, producing great debility, diarrhoea, and aphthous affections of the 
mouth. These symptoms persisted for six months, and induced Dr. R. to think of 
extirpation. The uterus, however, gradually lessened, till it acquired the size of a 
large pear, the os uteri tightly girting the neck of the tumour during the whole pro- 
gress of the case. The discharge became more purulent, and on examination at the 
end of seven months from delivery, no tumour could be detected ; the remains of the 
os uteri could be felt, but no regular aperture, the upper part of the vagina forming 
a complete kk cul-de-sac." She lived several years, and afterwards died °of cholera. 

Case 4 was Mr. Dick's. Dr. Radford detached the placenta prior to reduction, as 
had been done in Cases 1 and 2. There was little hemorrhage. The uterus was 
compressed between the hands, and easily carried up, until the vagina was made 
tense. There was now more resistance, but by steady pressure it was passed through 
the os uteri, and the hand was retained in the uterine cavity till contraction took 



DISPLACEMENTS OF THE UTERUS. 403 

2. Inversion of the unimpregnated uterus is an exceedingly rare 
event ; and, so far as our knowledge extends, has generally been pro- 
duced by polypus, the development of the walls of the utdrus being 
much less than what occurs in pregnancy. It has happened, indeed, 
where polypi have remained attached to the puerperal womb ; and it 
might have been expected, from the expulsive actions they have ex- 
cited, not only that their own protrusion would have occurred, but also 
inversion of the womb ; that in these very examples, neither the one 
nor the other event has taken place, although the uterine structure must 
have been considerably relaxed and developed.* 

place, the wrist being firmly grasped by the os. The patient recovered without any 
interruplion. 

Case 5 was a tedious labour, owing to a contracted pelvis. Dr. Radford failed 
with the long forceps, and delivered by perforation. The uterus was inverted spon- 
taneously, the cord not having been touched at the time. The fundus had partially 
passed through the os, forming a tumour, globular, large, hard, and resistent, with 
the placenta attached nearly in the centre. The hand was introduced into the va- 
gina, and the tumour pushed upwards without much difficulty. The depending part 
of the tumour seemed to retire from the hand with considerable force. The placenta 
was then separated and removed. There was neither flooding, faintness, nor con- 
vulsion, and the patient recovered well. 

In Case 6, the inversion was not discovered till several days after labour. There 
was much difficulty in passing urine, and the catheter was used. This was at the 
first visit in the evening, and then the uterine tumour was felt above the pubes. She 
was very low, and grew weaker for two or three days; and on examination a tumour 
was found low down in the vagina, protruding indeed through the os externum. Dr. 
Radford at first thought it was procidentia, and attempted to return it, but did not 
succeed. In consultation several days afterwards, the patient suffered much from 
attempts to reduce it ; afterwards it was determined to be inversion, and the redac- 
tion was happily accomplished in about fifteen minutes. In this example the inver- 
sion was spontaneous, as there was no effort made to remove the placenta by pullina 
the funis. 

* Dr. Oldham (Guy's Hospital Reports, April, 1844), in an interesting paper on 
polypus uteri coexisting with pregnancy, says, " that the action of the uterus, in its 
attempt to effect the descent of these growths, sometimes displaces and drags with it 
the walls of the uterus, to which it is attached, inverting it. This circumstance has 
been attributed to the weight of the polypus ; but in three preparations which I have 
seen, showing this occurrence, the polypus has been by no means large, and seemed 
insufficient to produce such a result. It is rather to be attributed to the constant 
action of the womb; and I know of no instance where the residing intrinsic force is 
so well exemplified. A very interesting preparation of this kind was sent me by 
Mr. Duke, of Kennington. The poor woman, the subject of it, was between 50 
and 60 years old, and a virgin. She had been suffering for some time from oc- 
casional hemorrhage, and afterwards from an offensive discharge. Her countenance 
was anxious ; the pain in the uterus severe; and she was thought to be the subject 
of malignant disease. She refused to permit a local examination; and she died, 
worn out with the discharge and bleedings. In this instance, the right horn of the 
uterus is completely inverted. The polypus, which is the size of a small orange, has 
no proper pedicle ; but it merges insensibly into the inverted portion of the womb. 
Its structure is firm, compact, fibrous, and very resistent when cut through. Its 
lower free surface, which has passed beyond the os, having freely dilated it, is 
sloughy and ulcerating; and on the right side is seen a large patch of a fungoid 
growth, which is imitated by one of about the same size and character on the con- 
tiguous surface of the expanded womb " 

The following case occurred in St. Bartholomew's Hospital, and is sufficiently im- 
portant to be recorded in Dr. Rigby's own words. The uterus apparently became 
suddenly inverted after he had tied a protruding polypus, and was removed by him 
with the polypus by a second ligature. 



404 DISPLACEMENTS OF THE UTERUS. 

3. The rapid dissolution sometimes following the accident, cannot 
always be attributed to hemorrhage; for sudden sinking and collapse 
succeeded by almost immediate death, have resulted from the inversion 
itself, at least there has been no loss of blood. Hence the vast impor- 
tance of the exhibition of stimulants and of immediate reduction. 

4. There are women, when the inversion has either not been dis- 
covered or could not be reduced, who survived many years, and a very 
small number who have suffered from permanent inversion compara- 

"Jan. 1844.-— Mary Hill, aged 50, was admitted into St. Bartholomew's Hospital 
two and a half years ago, on account of a polypoid growth of about the size of a 
small orange, which projected infn the vagina: the pedicle was thick, and appeared 
to spring from the upper part of the uterus; it was firm and fleshy to the feel, and 
did not present the ordinary character of a malignant growth. A ligature was 
passed rather low down upon the pedicle, and tightened without producing pain. 

"During the night, bearing-down pains came on, like those of labour" which ex- 
pelled a large, irregularly-shaped, fleshy mass, at the end of which was the lobular 
growth which had been tied. The mass was as large as a calf's heart, and appeared 
to be of the same structure as the polypoid end, on which the ligature had been 
placed; it did not appear to be sensible; and the patient, with the exception of a 
dragging pain in the loins, like that of prolapsus uteri, felt rather relieved than other- 
wise by its expulsion. As the mass filled up the vagina so completely as to preclude 
examination by the finger to any distance, I could only ascertain that the extruded 
mass was attached by a thick, firm fleshy pedicle, which went up far beyond my 
reach. Another ligature was applied low down the vagina, which also produced no 
pain, and was tightened every twelve hours. On the second or third day, profuse 
hemorrhage arose from the rupture of a considerable-sized venous trunk, which had 
become very turgid : pressure and caustic were applied without success; and it was 
ultimately taken up and tied with a portion of the surrounding structure. One or 
two other vessels burst shortly afterwards; and these repeated attacks of hemorrhage 
much reduced her. It being summer time, the mass began to putrefy rapidly ; and 
in spite of chloride of lime, &c, the putrid portions had to be removed daily by the 
knife, to diminish the effluvia. The ligature and the remaining portion came away 
at about the fourteenth day. She regained her strength, and she became an out- 
patient. 

" On examining her, about a month afterwards, Dr. Rigby found the vagina healthy, 
with a cicatrix-like spot, where the os uteri ought to have been ; but evidently with 
no uterus above it : the canal was somewhat contracted at its upper extremity, form- 
ing a cul-de-sac." 

The following examples I owe to Drs. Churchill and Nauche : — 

"Bridget Mahon, aged 52, mother of ten children : her last confinement took place 
nine years ago; admitted into .Tervis Street Hospital, June 5, 1835, under Surgeon 
Lynch ; was seized about three years ago with whites, which continued for two years: 
she attributes the attack to excessive mental anxiety and fatigue. 

"Her health, from the commencement, gradually declined, the debility and ema- 
ciation so great, that she was frequently obliged to remain in bed. 

" Being seized with a severe fit of vomiting, she experienced a sensation as if some- 
thing within her had given way, but did not make any examination at the time; 
about three days afterwards, was alarmed by the appearance of a tumour at the ex- 
ternal parts, which she reduced by moderate pressure with the fingers. It remained 
so for three months, the discharge still continuing. One day she°sat down to pass 
water, the tumour again appeared, but was reduced, and remained so for the next 
twelve months. 

On the first of June, as she stepped over a potatoe furrow, the tumour was com- 
pletely expelled, suspended between the thighs, in which state it still remains. 

"Her labours were all easy, and during the whole course of the disease, she did 
not experience, any difficulty in emptying either the bladder or rectum. 

"The tumour consisted, at the lower part, of a large double-headed polypus, at- 
tached by a thick and very short pedicle to the fundus uteri, which was completely 
everted, and formed the upper portion of the protruded tumour." 



DISPLACEMENTS OF THE UTERUS. 405 

tively slight inconvenience. The reverse of this statement, however, 
is almost universally true. 

Diagnosis. — The recognition of complete inversion cannot be diffi- 
cult, either in the puerperal or unimpregnated state. The volume of 
the tumour, the rough and bleeding surface, the absence of the os at 
its lower part, and the time of its occurrence, must prevent error. I 
can, however, understand that there may be considerable hesitation, 
where the inversion is incomplete, or where the fundus has scarcely 
passed through the os. Here doubt will arise as to the nature of the 
substance which the finger touches within the uterine cavity. It may 
be a polypus, a sub-mucous, or a scirrhous tumour as well as inversion. 
Nor would doubt be entirely removed, if a cup-like or even a greater 
depression were felt at the fundus ; for this might be produced by the 
dragging of an attached growth. Partial inversion, complicated with 
polypus, may perplex, but doubt will be removed when further descent 
occurs ; as then the point of attachment of the inverting body will be 
seen, and the protrusion of the fundus through the os will also be evi- 
dent. Most polypoid tumours are insensible : the lining membrane of 
the uterus generally possesses considerable sensibility, especially where 
the inversion is recent. But with all these diagnostic marks, there may 
still be hesitation ; for even by able practitioners a polypus has been 
mistaken for inversion, and inversion for polypus. But repeated ex- 
amination will correct such error, and lead to an accurate diagnosis.* 

An inverted womb then may be distinguished from polypus by the 
circumstances attending its descent, occurring suddenly, during or soon 
after labour ; by the tumour, which is large, less solid, and more com- 
pressible and elastic than polypus : by its external covering being 
rough, pale, and very unlike the smooth, shining and coloured invest- 
ment of most polypi. These latter growths, excepting only such as 
spring from the os and cervix, are encircled by the os uteri, which is 
not the case in complete inversion ; and even in the examples of par- 
tial inversion, the finger cannot pass round the neck of the tumour and 
between it and the os uteri, as in polypus. Let it also be remembered, 
that the inverted womb is tender to the touch, independently even of 
pressure. 

From prolapsus the distinction is easy ; there is no os uteri inferiorly ; 
from prolapse of the vagina — a rare affection to any extent — inversion 

A case is related by Leblanc, of a female who " was attacked with violent pains 
after suppression of the menses for three months, and to these succeeded a con- 
siderable hemorrhage, which was followed by the protrusion of a voluminous fleshy 
mass. Leblanc recognised a retroversion (inversion) of the uterus, after a minute 
examination ;— he restored the uterus, and the woman recovered perfectly." 

I have given these cases in a very abridged form, because they illustrate and con- 
firm some very important points in the history and treatment of this serious malady. 
The profession is under great obligation to their able authors. 

* M. Velpeau (Medical TimesrSept. 21st, 1844) says, in reference to a case of 
supposed polypus, on which he operated, that it was only from the pain of the ope- 
ration, that he felt certain it was inversion of the uterus and not polypus. Again he 
states, "about a year ago I operated on a woman, and was at first undecided whether 
I had removed a polypus or the uterus; but it was the former." The woman died 
from intense peritonitis; — at the autopsy the uterus was found to have been inverted 
by the dragging exercised on it by the polypus. 



406 DISPLACEMENTS OF THE UTERUS. 

may be distinguished by its size, rough, flocculent, and bleeding sur- 
face. 

Treatment.— In recent inversion, the great object is to reduce the dis- 
placed organ ; and even where the malady is chronic, it will remain to 
be determined whether reduction be practicable. If, happily, medical 
aid be early called for, reduction will not be difficult ; but it is of the 
utmost consequence that it be attempted speedily. Denraan thought 
it nearly impossible beyond four or five hours ; and with his wonted can- 
dour he said, that in really chronic inversions, he had never succeeded 
in any one instance, though the trials were made with all the force he 
dare' exert, and with whatever skill and ingenuity he possessed, so that 
the reposition of a uterus which had been long inverted he concluded to 
be impossible. 

Time, however, within moderate limits, if other circumstances are 
favourable, is a difficulty which may be overcome. Where the inver- 
sion is not complete, or being so, the tumour is not large ; where the 
vagina, os externum and os uteri are not contracted, but soft and dila- 
table ; and where the practitioner is persevering, skilful, and deter- 
mined, reposition will often be effected in cases which would have 
been given up as hopeless by Denman, Hunter, and Ford. 

Whether the placenta, if detached, should be separated prior to re- 
duction, is a point on which there has been considerable difference of 
opinion. In neither of my cases, although I tried for some minutes, 
could I return the uterus within the placenta ; but in neither did hemor- 
rhage precede or follow its separation. Where the os is firmly con- 
tracted, there is little risk of bleeding, for the uterine vessels are effect- 
ually constricted at the upper part of the tumour. Reduction must be 
facilitated by the previous removal of the placenta, adhering as it gene- 
rally does, to the fundus, the part to be first returned. Denman cau- 
tiously remarks, " that where the placenta is partly separated, it would 
be proper to finish the separation before reduction is attempted ; but if 
the placenta should wholly adhere, it will be better to replace the ute- 
rus before we endeavour to separate the placenta." This is not sound 
advice ; for, where the placenta is thus partially separated, hemorrhage 
is either present or highly probable. Now if there has already been 
bleeding from the partial detachment of the viscus, and we know how 
rapid floodings sometimes are, it certainly would be very unsafe, by 
completing the detachment of the placenta, to uncover more of the 
uterine sinuses, and thus to increase the patient's danger. The better 
practice would be at once to attempt the reposition, trusting to uterine 
contraction being excited, so soon as the organ was returned into the 
pelvic, cavity, this great point being additionally secured by the stimu- 
lus of the hand within. Denman urges as the ground of his advice, 
" that while we are separating the placenta, the cervix of the uterus 
is speedily contracting, and the difficulty of replacing it increasing, 
which is a far greater evil than a retained placenta." Where the cer- 
vix thus contracts, and goes on contracting, the risk of hemorrhage is 
slight, and the difficulty of reduction great; a difficulty which should 
not be increased by permitting the placenta to augment the size of the 
already too bulky uterus. 



DISPLACEMENTS OF THE UTERUS. 407 

We may then conclude, that where the protruded organ and its at- 
tached placenta do not together make up a large tumour, and where 
the os does not constrict its upper part, reduction of the whole may be 
at once attempted ; where, however, these favourable conditions do 
not exist, it will be wiser to insure reposition by previous separation. 

Nauche recommends, if the return of the inverted womb is seriously 
hindered by the firm contraction of the circular band of fibres forming 
the cervix, that it shall be divided by the knife or bistoury ; a practice 
which can scarcely be necessary, if the cervix be free from organic 
disease. 

At what period after inversion is reduction to be regarded as hope- 
less? It may have existed some days before being recognised; are 
we then to give up every attempt to reduce it ? Certainly not. The 
utmost effort is justifiable, apart from violence and long-continued pres- 
sure. The miserable condition of a woman with a permanently in- 
verted womb, ought to prompt the employment of every measure 
favourable for its reduction ; and Dr. Radford has justly observed, 
"that the womb has been re-inverted after a considerable length of 
time, of six or seven hours, of seventeen hours, of twenty-four hours, 
of twenty-seven hours, of three days, of seven days, of eight days, and 
in one case after it had existed twelve weeks." 

If the accident occurs while we are in the chamber, we need not 
delay the attempt at replacement by emptying the bladder and rectum ; 
but if several hours have elapsed, the evacuation of these viscera will be 
a necessary preliminary. If, owing to undue delay, the uterus and ad- 
jacent parts have become swollen and tender, and if the pulse be full 
and the patient feverish, bleeding, the exhibition of tartarized antimony, 
so as to produce nausea, not vomiting, and poppy and conium fomen- 
tations will, by diminishing the congestion of the uterus, reduce its 
size and facilitate its re-inversion. 

Before commencing reduction, the back of the right hand should be 
thoroughly smeared with lard or oil, and the lowest portion of the 
tumour should then be firmly grasped, the fingers acting upon its upper 
part, and in this way returning the portion last protruded. For a time 
little or no progress may appear to be made, the womb only altering its 
position, but without diminution of bulk. Soon after, however, the 
tumour begins to enter the pelvic cavity, and the vagina is put upon 
the stretch ; the effort being continued, and perhaps slightly increased, 
the tumour recedes still further, when at length it suddenly starts from 
the hand, passing quickly through the os (like a re-inverted India rub- 
ber bottle), and is thus in an instant replaced. The hand, whether the 
right or left, being now in the cavity of the uterus, should not be im- 
mediately withdrawn ; for its presence excites contraction, and it should 
be expelled rather than taken away. 

It has been advised to introduce a pessary after reduction, in order 
to maintain the replaced uterus; but I cannot see any good likely to 
arise from this practice. The pessary must, under such circum- 
stances, be a large one ; and although it may produce irritation and 
discharge, it is not easy to perceive how it should prevent sinking of 
the fundus. Of course a longer time than usual must be passed in bed 



408 DISPLACEMENTS OF THE UTERUS. 

or in the recumbent posture, and sudden movements of the body should 
be carefully avoided. 

The inversion may, however, be irremediable, and we shall then 
have to determine what are the best palliative measures ; and, if these 
be unavailing, whether extirpation must not be resorted to. Burns 
says (Midwifery, p. 488), " when the uterus cannot be replaced, we 
should at least return it into the vagina. We must palliate symptoms, 
a Pp!y gentle astringent lotions, keep the patient easy and quiet, attend 
to the state of the bladder, support the strength, allay irritation by ano- 
dynes, and the troublesome bearing down by a proper pessary. A 
spring bandage is also useful. If inflammation come on, as it does 
usually, blood-letting, antiphlogistic and aperient remedies will be re- 
quired. After a time, by this treatment, the uterus contracts to its na- 
tural size, and the woman menstruates as usual, but generally the health 
is delicate. Sometimes the organ becomes scirrhous or gangrenous, 
and sloughs take place." 

We have now abundant proof that the uterus maybe safely removed, 
especially when it has been beyond the external parts for any length of 
time ; and that its spontaneous separation may occur without either de- 
stroying life or involving it in serious risk.* The womb has been 
destroyed by gangrene, and yet the patient has recovered ; and in Dr. 
Radford's and some other cases it appears to have sloughed off without 
serious consequences 

Sir Charles Clarke, whilst approving of the operation in those cases 
where the comfort of life was destroyed and its continuance endangered 
by excessive discharges, still hesitate as to its propriety previously to 
the decline of menstruation ; but the operation has been safely and suc- 
cessfully performed even at this age. 

Extirpation, therefore, is not only justifiable, but necessary, especially 
if there be no unfavourable circumstances. Dr. Churchill thinks it 
should notbe performed " if the uterus be affected with scirrhus or can- 
cer." This, in my opinion, ought to be an additional inducement, if 
the affections are confined to the uterus itself, and have not implicated 
the vagina or external genitals. 

Burns mentions a case from Schmucker's Surgical Essays (Art. xvii.), 
" where an appearance of gangrene, from strangulation, took place. 
The womb was scarified, and the swelling quickly disappeared. The 
patient recovered." 

The inverted uterus, being mistaken for the child's head, has been 
torn off with the crotchet. Petit of Dijon says, a surgeon by mistake 
applied^ a ligature round the inverted womb, and cured the woman ; 
and Osiander relates a case where the midwife pulled down the uterus 
and placenta, and cut them both away. The patient recovered, and 
was afterwards exhibited during every course of his lectures. Bartho- 
lin states, that the inverted womb was once torn away, and found under 
the bed after the death of the patient. In Recueil des Actes de la So- 
ciete de Sante de Lyon, it is recorded that the uterus was mistaken 

* In the Dublin Journal for September, 1837, Dr. J. C. Clarke has published a case 
in which the inverted uterus with the ovary separated shortly after delivery. The 
lacteal secretion was suddenly suppressed, and the sexual propensities ceased. 



DISPLACEMENTS OF THE UTERUS. 409 

for polypus, and the ligature applied. The mistake being discovered, 
it was instantly withdrawn, but the woman died in a few days. 

The operation of removal consists in the application of a ligature 
round the highest part of the tumour, and its gradual tightening till it 
has entirely cut it through. Such a procedure cannot be free from risk, 
and the greatest care must be taken that nothing be included but the 
tumour. Frequent loosenings of the ligature may be necessary on ac- 
count of pain ; but these will only delay the progress, without inter- 
fering with the success of the measure. Silk, whipcord, silver wire, 
and fishing line have all been employed ; but whipcord, probably more 
commonly than any other. Mr. Newnham's case is so clearly described, 
and its result so satisfactory, that I shall give an abstract of it.* 

Burns and Windsor, after tightening the ligature to a certain degree, 
have immediately removed the tumour by the knife. Similar opera- 
tions have been performed by Gooch, Granville, Chevalier, and others, 
and generally with favourable results ; although it must not be sup- 
posed that these are always successful. Deleury's case proved fatal in 
a few days ; and death ensued after operations of the same kind by 

* Mrs. G was delivered on the 21st of January, 1817, of her first child, after 

a natural labour. The funis was remarkably short, the placenta adherent, and much 
hemorrhage succeeded its removal; retention of urine supervened, requiring the 
use of the catheter. The patient consulted Mr. Newnham early in April, " on account 
of a constant discharge from the vagina of a mucous character, accompanied with 
frequent hemorrhage." " On those days when she had the least discharge it was 
still very considerable, and required seven or eight napkins in every 24 hours, in or- 
der to keep her comfortable; but the returns of active hemorrhage were increasingly 
frequent, and were induced almost by the slightest exertion." Her constitution was 
seriously injured, and her appearance was that of a person suffering from large he- 
morrhages. "On examination, 1 discovered, in the vagina, a tumour of considerable 
size, somewhat of a pyriform shape, larger at its base than at its superior extremity, 
but not attached by a very narrow neck — surrounded at its apex by the os uteri, be- 
tween which and the tumour the finger could be readily passed, without discovering 
any immediate connexion ; as far as I could ascertain, nearly insensible ; and which 
had never occasioned pain." After a consultation with Mr. Oke, of Farnham, it was 
decided to be inversion of the uterus, and it was resolved that its removal by liga- 
ture should be attempted on Sunday morning, April 13, 1837. The ligature, of 
very strong silk, was applied "as high as possible, upen the neck of the tumour, 
taking care to avoid including any part of the os uteri, by carrying the silk within 
the orifice." A full dose of opium was given, and the patient complained only of a 
little uneasiness on the sides of the hypogastric region. 

On the 14th and 15th, the ligature was tightened, which gave considerable pain, 
and in consequence it had to be loosened. The opiate was repeated and some ape- 
rient medicine ordered. On the 17th, there was much pain and some tenderness on 
the left side of the hypogastric region with a quick pulse, which induced Mr. N. to 
remove the canula and leave the ligature quite loose. 

On the 18th, as all unpleasant symptoms had disappeared, the ligature was tight- 
ened, an opiate enema given. From this day till the 6th of May, "the ligature was 
daily tightened, the pain continued until the 30th of April, after which it gradually 
diminished. On the 26th of April and 2d of May, the patient became excessively 
irritable, but this subsided. The discharge was fetid after the 24th, and in consi- 
derable quantity after the 29th. "When the ligature was tightened, this evening 
(May 6th), the tumour became detached, and I found to my no small satisfaction 5 , 
that it was, as 1 believed, an inverted uterus." Essay, p. 31, et seq.— {Diseases of 
Females by Churchill.) 



410 DISPLACEMENTS OF THE UTERUS. 

Desault and Baudelocque. Boivin and Duges mention two fatal cases, 
where the inverted uterus was mistaken for polypus. 



Case 83. 

inversion of uterus immediately after labour. 

Mrs. G 11, set. 28, residing in Spitalfields, was delivered, July 20, 1828, of a 

healthy boy. In a few minutes afterwards she complained of a sudden and violent 
pain low down in lhe belly, and said l, she was sure either that another child was 
coming, or that the whole inside was dropping- through the passage." The midwife 
(Mrs. Carter), on examining, found a large tumour (the inverted uterus with the 
placenta adhering) between the thighs. She was naturally much alarmed, and a 
neighbouring practitioner having been sent for, requested my immediate attendance. 
I was there very soon, probably not more than three-quarters of an hour after the oc- 
currence. Her state was most alarming; the pulse was quick and compressible; 
she was bedewed with cold perspiration, and fatal collapse appeared rapidly approach- 
ing. There had been no hemorrhage, and the inversion was entirely spontaneous. 
Brandy, only slightly diluted, was instantly given ; indeed, in small quantities, it had 
been exhibited before my arrival ; and while this was being done, I grasped the. tu- 
mour and tried to return it; but I could not reduce any part of it within the pelvic 
cavity, the mass was so large. At once, therefore, as she had not had hemorrhage, 
1 detached the placenta, peeling it off without any difficulty. There was still no 
bleeding of any consequence. Immediately afterwards I made another attempt, and 
was pleased to find the uterus passing slowly upwards. My right hand entered 
the vagina as it was being re-inverted, and the last portion of the uterus passed 
through the os almost with a jerk. I kept my hand in the cavity for several minutes, 
till firm contraction compelled its withdrawal. For two hours there was only a very 
gradual improvement ; but the brandy seemed at length to have some effect, although 
doubtless the restoration of her sunken power was principally attributable to the 
reduction. !8he recovered slowly, but without any deviation from the usual course 
of convalescence. 



Case 84. 

spontaneous inversion of the uterus without hemorrhage. 

The subject of the onty other case I have seen was a poor woman, Mrs. C, re- 
siding in one of the courts leading from Fenchurch Street. She was nearly 40 
years of age, had borne many children, and was compelled to work very hard at 
glove washing. I had seen her several times in her former labours, and on one oc- 
casion, she was all but dead from hemorrhage consequent on the expulsion of an 
ovum of only eight weeks. (The preparation is in St. Thomas's Hospital Museum.) 
I saw her a very few minutes after the inversion had taken place. It was entirely 
spontaneous, for a friend who was with her during the labour assured me, that the 
midwife did not even touch the cord. The child was pushed into the world very 
quickly ; and before the nurse had left the bedside three minutes, Mrs. C seemed to 
have a sudden but momentary pain, and exclaimed, " that something else was coming, 
and that she should die." The discovery was immediately made, that the after-birth 
as it was supposed, had been expelled ; but as she was deathly pale and faint, they ran 
to my house, begging that I would see her instantly. I did so, and found the uterus 
completely inverted, with the placenta adherent; but she had not lost any blood. 
The pulse was rapid ; she was pale and cold, and exceedingly alarmed, and if she 
had been vomiting, and 1 had not known that the womb was inverted, 1 should have 
had no doubt that laceration had taken place. Strong gin and water was given, and 
an immediate attempt was made at reduction. I was fearful, from my knowledge 



DISPLACEMENTS OF THE UTERUS. 4H 

of her, that even slight hemorrhage would sink her, and therefore I did not remove 
the placenta previously, but I was entirely foiled ; and although I used considerable 
effort for more than ten minutes, I could not return the smallest part of the tumour. 
Without any hesitation, therefore, I peeled off the placenta, during which there was 
very little blood lost ; and then, but not without a good deal of difficulty, the uterus 
was returned. The syncope and quick breathing continued for more than an hour after 
the reduction; and it was not till sulphuric ether, ammonia, and brandy had been 
largely given, that she entirely rallied. It was more than three weeks ere she had 
sufficiently recovered to resume her usual avocations. 



Case 85. 

INVERSION OF UTERUS IMMEDIATELY FATAL FROM HEMORRHAGE. 

COMMUNICATED BY DR. LEVER. 

Mrs. , set. 36, the mother of several children, and delicate, was confined, after 

a quick labour, of a living child. In a few minutes, without any traction on the 
cord, the patient complained of sudden pain, and said something more had been ex- 
pelled. The surgeon immediately passed his hand above the pubes, but could not 
detect the womb. An attempt to make vaginal examination, satisfied him that the 
Bterus was completely inverted. Without the loss of a moment he tried to return 
it without previous separation of the placenta, but failed. He now peeled off the 
atter-birth ; but as there had been some blood lost already owing to its partial de- 
tachment, the entire separation was attended with such fearful flooding, that she 
sank almost immediately. 



ANTEVERSION AND ANTEFLEXION OF THE UTERUS. 

There is no doubt in the profession about the existence of proci- 
dentia, inversion, and retroversion ; but there are many well-informed 
practitioners who question whether the uterus is ever anteverted, ante- 
flexed, or retroflexed.* It is true these states sometimes require nice 
diagnosis ; that they are exceedingly uncommon ; that in slight and even 
more marked degree, they may exist undetected ; that they are rarely 
productive of serious symptoms: and that perhaps in few instances 
can they be said to have caused death— but still they exist. It is 
therefore important that they should be fully described. 

In anteversion the uterus is placed transversely in the pelvic cavity, 
the fundus lying forwards, directly behind the bladder, pressing its 
posterior against its anterior wall, the cervix being tilted upwards and 
backwards towards the sacrum. In this stage there is no flexion ; but 
where the disease has been unsuspected and its cure consequently un- 
attended, the anteversion may be so complete, that the uterus will be 
flexed on itself, the posterior surface of the fundus looking forwards, 
the anterior downwards, and the cervix tilted upwards towards the 
junction of the sacrum and spinal column. 

In anteflexion, the body of the uterus is bent forward so completely, 

" M. Lisfranc affirms "from hundreds, he might say, thousands of observations" .'/ 
that anteversion is infinitely more frequent than retroversion. 



412 DISPLACEMENTS OF THE UTERUS. 

that its posterior wall becomes antero-superior, lying immediately be- 
hind the symphisis pubis; but the cervix retains its position in the 
centre of the vagina, entirely unchanged.* Thus the distinction be- 
tween the two displacements is, that in anteversion there is not of 
necessity any flexion of the uterus, although it may occur, and the 
cervix suffers decided change of position ; while in anteflexion, the 
uterus is always bent more or less completely upon itself, and the 
cervix retains its natural situation. 

These affections can only happen while the uterus is nearly of the 
natural size ; if, therefore, they take place at the beginning of preg- 
nancy, its progress and completion will probably rectify the displace- 
ment. The point of flexion is usually a little above the union of the 
cervix with the body of the uterus, and the degree of curvature deter- 
mines the slightness or severity of the affection. In Boivin's case, the 
uterus was completely doubled on itself. There is often great rigidity 
at the seat of the flexion; and the consequences of chronic inflamma- 
tion, such as thickening and other changes of structure, are sometimes 
recognised. In the only well-marked case that has come under my 
observation, where the patient was pregnant, I could not easily move 
the uterus upon its cervix. Probably the bladder, which is so fre- 
quently allowed to be full in women, may be a barrier against the 
frequent occurrence of this affection. Anteversion may prevent con- 
ception from displacement of the os and cervix ; but this is by no means 
a frequent result. "Pregnancy," Madame Boivin thinks, "may, in its 
first period, dispose to anteflexion ; in its later periods it may, by the 
changes in the state and size of the uterus, lead to a cure ; labour will 
be apt to be followed by relapse, which must be prevented by frictions 
on the hypogastrium, and a strict attention to the condition of the 
bladder and rectum." 

Anteversion with flexion may sometimes be congenital ; at least it 
has been met with in young and unmarried persons. Such cases ought, 
perhaps, to be attributed to rapid and disproportionate growth of the 
womb about the time of puberty. 

Causes. — Age does not seem to have much influence, as these affec- 
tions have been observed at all periods, even from childhood to ad- 
vanced life. Lymphatic, meagre persons are, as might be supposed, 
particularly liable. Parturition is not an active cause, as married wo- 
men who have never borne children have been the subjects of both. 
Duges gives a case, in which the fundus fell between the adjacent 
walls of the vagina and bladder in the twelfth week of pregnancy. 
Great breadth of the vagina may be regarded as predisposing to the 
affection. 

In many of the recorded cases there has been menstrual disorder, 
leading to congestion; but it will often be difficult to determine whether 
engorgement precedes anteversion or follows it. 

The direct causes, those producing immediate displacement, are, falls, 
violent and sudden muscular efforts, straining at motion, or in the eva- 
cuation of the bladder, slow or gradual anteversion and anteflexion 

* Vide Madame Boivin's Atlas, plate 9, fig. 6. 



DISPLACEMENTS OF THE UTERUS. 413 

may result from hypertrophy of the anterior parietes of the organ, not a 
very uncommon event, owing to the greater exposure to injury of this 
part than the posterior wall ; tumours at the fundus ; pelvic growths 
favourably situated for pushing the organ forwards; and possibly, large 
abdominal tumours. 

Symptoms and Diagnosis —If the displacement has been sudden, the 
accession of symptoms will be marked ; but where it has been slowly 
effected, the inconvenience will come on so gradually, that it will be 
nearly impossible to tell the precise time of their origin. A fall from a 
steep stair (Case 86), the bowels being excessively constipated, ante- 
verted the womb, which was at once recognised by a vaginal examina- 
tion. The most constant and wearing symptom is a sense of fulness 
and weight low down behind the pubes, " a bearing down," in popular 
language, accompanied by weight and pain about the perineum and in 
the rectum ; a frequent desire to pass water and difficulty in doing so. 
There are also pains in the back, groins, and thighs ; but in the & case 
already mentioned, the greatest suffering arose from pressure on the 
bladder. Exertion, the erect posture, walking or riding, and relieving 
the bowels aggravate, while the recumbent posture alleviates the dis- 
tress. 

It must not, however, be supposed, that these evils are always pre- 
sent, or that when they exist, it is always in aggravated degree. In 
Dr. Walshe's case, defecation was unusually difficult, but there was no 
pain in passing the water. Lagrand and Rayer in two instances found 
the contents of the bladder and rectum were excreted with facility. 
The severity of the symptoms will a good deal depend on the com- 
pleteness of the displacement, and on the degree of flexion, although 
this is not always the case ; for in some recorded examples, where the 
flexion was great, and the cervix not at all displaced, there was great 
difficulty in defecation, but none in relieving the bladder. 

_ Leucorrhcea is a usual accompaniment, nor are disordered menstrua- 
tion and hemorrhagic discharges uncommon. Retention of the cata- 
menia may be regarded as one of the rare results. 

. The foregoing symptoms are indicative, without being confirmatory 
either of anteversion or anteflexion ; but if on examining by the vagina, 
the cervix is difficultly reached, and with its orifice close to the sacrum ; 
and if a firm tumour is found at the anterior wall of the vagina, filling 
up the pelvis and pressing on the lower part of the bladder— such ev£ 
dence will leave no doubt. Examination by the rectum may occasion- 
ally help us to reach the cervix, when we cannot effect this by the 
vagina. J 

If these points are clearly made out, the diagnosis is established ; 
and it may be aided by introducing a metallic bougie into the bladder, 
when the solid uterus will be impinged upon, and of course the sound 
will be different rrom that produced by striking a calculus. Levret, 
however, was once deceived, and the operation for lithotomy was un- 
fortunately performed, the mistake not being discovered till after the 
death of the patient. 

From retroversion these displacements may be distinguished by the 
fundus being anterior and the cervix behind. 
21 



414 DISPLACEMENTS OF THE UTERUS. 

From pelvic and ovarian tumours, by the history of the cases, and 
by the presence, in these latter affections, of the os uteri in its proper 
place. 

Prognosis. — If anteversion and anteflexion are uncommon diseases, 
they are happily seldom fatal ones. There does not appear to have 
been any instances as yet recorded, where, without some complication 
with other disease, death has ensued. 

Treatment. — It is not difficult to suppose that the slighter cases may 
be cured almost spontaneously, at least if aided by the filling of the 
bladder and the emptying of the rectum. In my own case, the advance 
of pregnancy led to reposition, and that without anything beyond the 
simplest treatment. If congestion or chronic deposit have resulted 
from metritis, appropriate antiphlogistic treatment may assist the uterus 
to resume its healthy position. If these evils do not exist, and the 
patient be irritable, the mildest means must be tried, such as gentle 
aperients, salines, and the recumbent posture. 

If, however, manual interposition become necessary, there may be 
serious difficulty. The patient should be placed on her back, w T ith the 
pelvis elevated and her knees raised, and while, by one finger in the 
vagina, the cervix is hooked and drawn down to its proper place, with 
the other hand gentle, but persevering pressure should be made, on the 
fundus in the hypogastric region. 

If the taxis so employed is unavailing — if the cervix cannot be 
reached in this way — the instrument invented by Boivin, w T hich is in 
fact one branch of the forceps, about six inches long and curved in the 
form of an italic /, may be employed. The blade portion, with its 
convexity towards the sacrum, is to be passed up the vagina till the 
cervix can be seized in its fenestra. If this can be done, its depression 
may be regarded as almost certain. 

The recumbent posture must be strictly observed for some time, and 
any exertion requiring deviation from this posture must be avoided ; 
defecation should be rendered as easy as possible. If there be leu- 
corrhoea or menorrhagic discharges, astringent injections should be 
used. Pessaries have been recommended, it being supposed that by 
acting on the vagina they will steady the womb ; but it is doubtful 
whether they can do any good. In anteflexion, where the cervix is 
already centrally placed in the vagina, they can effect nothing ; and in 
anteversion, the lying down and the avoidance of effort are the only 
efficient means. 

Dr. Walshe alludes to the complication of retention of the catamenia, 
and says, " it was boldly and successfully combatted by Gauthier, by 
making an incision about two inches long, in the antero-inferior part 
of the uterus, from right to left. The operation was followed by the 
evacuation of four pints of menstrual fluid, and instant relief of several 
bad symptoms that had arisen. The catamenia regularly passed 'after- 
wards through the artificial opening, and the same route was taken (so 
we are allowed to suppose at least) by three infants, of whom the 
patient was afterwards safely delivered." 



DISPLACEMENTS OF THE UTERUS. 415 

Case 86. 

* 

ANTE VERSION AND ANTEFLEXION TERMINATING FATALLY. 
COMMUNICATED BY DR. WALSHE. 

This ease, says Dr. W., I had an opportunity of observing some years past, in the 
wards of M. Louis ; it is of some valu**, as there are only three or four, I believe, on 
record, in which the state of the uterus was established by dissection; and a still 
less number, in which the observation of the symptoms was followed by post-mortem 
examination. 

V. E., an 38, admitted December 16th, examined January 9th. 
Previous State — Has worked for the last three years as char-woman, was before 
that portress and housemaid. Catamenia appeared at the age of 16, without pain, 
perfectly regular from the outset in their return; lasted four or five days, with- 
out clots, swelling-of the breasts, or cephalalgia. Has had six children, first at the 
age of 17, last at the age of 23; no change in menses after confinements; no leucor- 
rhcea in their intervals. Has been subject for the last five years to pain near the 
upper border of the sacrum, after the least fatigue. Her food has been poor in qua- 
lity, she has not for years been in the habit of eating meat; considers herself ill since 
Nov. 10, previous to which time she had no sensation of bearing down at the anus, 
pain in groins, nor white discharge; for a month before, however", the sacral pain had 
increased, and she had only been very slightly unwell on thetwo preceding occasions. 
On that day, while employed in washing, a sudden flow of blood, with large clots, 
took place per vaginam, without her having made any particular effort. Feeling no 
pain she continued her work, and has since then had a persistent red discharge, 
which, for the first month, daily equalled the quantity lost in the same time during 
catamenia, and has latterly diminished. Inguinal pain at first considerable, now less! 
for the last fifteen days suffers from occasional pricking pain in the left thigh; has lost 
half her former flesh ; scarcely ate anything during the first month. 

Present State. — Skin dull, but not straw-coloured; decubitus right lateral, as it 
has been for the last two months; tongue moist, whitish ; abdomen indolent and lax, 
except towards pubis and left groin; the sacral pain still exists, but to a less degree 
than before ; has always been subject to constipation, but defecation unusually difficult 
for the last two mc:<th>, and increasingly so ; urine in proportion to drink, the patient 
makes nocomplaint of difficulty in passing it; no thoracic symptom; pulse 76, small, 
regular; inodorous vaginal discharge, equalling in quantity about an eighth of what is 
lost daily during menses. By speculum.— -Nothing remarkable in state of vagina ; im- 
possible to see orifice of uterus. Examination with finger. — Natural temperature 
of vagina; neck of uterus 2£ inches from vulva, broad, unusually hard, and turned 
backwards ; anteriorly towards the pubis a tumour is felt formed by the body of the 
organ; on pushing it upwards depression of the neck follows, the patient beino- in 
the recumbent position. " 



Infusion of cocquelicot, for drink. 

Gum draught, with rhatany root, in powder, gr. xxiv. 

Gummy extract of opium, gr. j. in pill. 

Vaginal injection, with decoction of morel and poppy-heads. 

Quarter diet. 

Jan. 20. Omit the opiate. 

Balsam of copaiba, gtt. xx., made into pills. 

28. Discharge increased for last six days; the general symptoms are, however 
much improved; colour comparatively fresh ; no pain ; appetite as in health ; sleep 
good ; she states, that were it not for the discharge she should consider herself per- 
fectly well. Omit copaiba; common diet. 



416 DISPLACEMENTS OF THE UTERUS. 

Feb. 12. A new train of symptoms appeared ; abdomen greatly swelled, and very 
tender; violent pain in hypogastrium. first slightly felt on the 9th ; bladder not dis- 
tended ; motions natural; frequent vomiting since yesterday of greenish matter; 
this is on the increase; no stool for four last days; tongue pale, moist; no cough ; 
pulse 1 12, regular, very small; discharge almost totally ceased; decubitus dorsal, 
knees raised ; features contracted, and expressive of extreme suffering. 

Fifteen leeches to hypogastrium. 
Enema of sulphate of soda, ^j. 
Solution of tartarous syrup, for drink. 

13. Vomited almost all her drink yesterday, but nothing since three, a.m. ; ab- 
dominal tension increased ; tympanitis to an extreme degree; the least percussion 
causes torture; hypogastric pain unrelieved ; no typhoid or other maculse on skin; 
tongue white, moist, no redness of borders; considerable thirst: enema has not been 
voided; pulse 126. regular, fuller than yesterday; no abnormal sound at precordial 
region; respiratory murmur distinct there; pulsation of heart feeble; no sound in 
carotids; respiration 54, deep ; auscultation gives normal results : voice a mere whis- 
per ; decubitus dorsal, as before. 

Repeat Enema. 

Extract of digitalis, gr. ij. in pills. 

14. Tongue as before; continual nausea ; vomited twice ; two stools, consisting of 
enemata only ; urine natural ; pulse 110, regular, pretty full ; respiration 48 ; abdomi- 
nal parietes almost motionless; tendency to somnolence; emaciation visible ; slight 
discharge per vaginam; skin dry, scarcely hotter than natural. 

Bottle of Seltzer water. 

Mercurial ointment, 3j- To be rubbed into the abdomen and upper part 

of the thighs, in half-drachm doses every hour. 
v Omit the digitalis. 

Expired at 9, p.m. 

Autopsy 36 hours after death : weather mild and damp. 

Exterior. — Considerable emaciation ; muscles well-coloured ; slight lividity of 
sides of abdomen; very .little cadaveric rigidity. 

Abdomen. — Diaphragm raised to level of fifth intercostal space; the tympanitis is 
found to have been produced by distention of small and large intestine, particularly 
of the former; convolutions of small intestine glued together by greenish false mem- 
brane, but no fluid between them ; left colon vertically, brick-coloured, surface mam- 
milated, and covered with a layer of viscid semi-fluid matter; transverse colon di- 
rected obliquely downwards to left iliac spine, whence it ascends to diaphragm, and 
then re-descends, being bound down in this position by false membranes; sigmoid 
flexure adherent inferiorly ; on breaking up the adhesions a quantity of dull red- 
coloured fluid is discovered, and the posterior surface of the intestine is perfectly 
black and covered with dark-coloured detritus; in the cul-de-sac between uterus and 
rectum is a clot of blood as large as an egg, surface black, not distinctly fibrinous; 
to account for it there appear to be some vessels open ; here, too, are several loculi, 
with pseudo-membranous walls, of hard white-of-egg consistence, and containing 
putrid clots; these being removed, a black layer of membrane is found adherent to 
the peritoneum, which is healthy underneath. Stomach. — Peritoneal surface brick- 
red colour; mucous membrane of natural consistence everywhere, rather thin in 
great cul-de-sac. and on posterior surface ; non-mammi!ated, no mucus on its surface ; 
sub-mucous tissue of great tuberosity infiltrated with reddish serum. Small intes- 
tine. — Walls, notwithstanding their distention, thicker than in normal state; mucous 
membrane pale or greenish throughout, consistence and thickness normal. Large 



DISPLACEMENTS OF THE UTERUS. * 417 

intestine contains a quantity of pultaceous greenish matter, especially rectum and 
sigmoid flexure; very wide all the way to the anus; mucous membrane natural. 
Kidneys, pancreas and spleen healthy. Liver covered with yellow pseudo-mem- 
brane, one line thick and fragile; cohesion of substance somewhat less than natural. 
Uterus flexed on itself at an obtuse angle at the union of its body and neck, in such 
manner that the fundus, concealed by ihe bladder, is inclined forwards and down- 
wards while the neck is inclined backwards to the sacrum, the posterior surface of 
the body being antero-superior. There is a slight lateral obliquity in its direction, the 
neck being turned somewhat to the right of the middle line, the fundus towards the left 
crural arch. The body of the organ, as well as the neck, is hypertrophous ; their sub- 
stance is of a grayish hue and hardened, firm, and resisting throughout, except at the 
union of those parts where there is a band of the organ, flattened from before to behind 
extremely soft, flabby, and yielding, and corresponding exactly to the angle of flexion' 
Ihe anterior and posterior walls of the body each measure precisely an inch in thick- 
ness ; the enlargement of the fundus is in proportion to that of the rest of the organ ; 
the neck is 2£ inches wide, at its orifice gaping, borders greenish in colour; cavity 
in no way remarkable. Ovaries.— Right : enlarged and divided into cells contain- 
ing a consistent pun form fluid. Left: also divided into loculi, filled with a citron- 
coloured serous fluid ; a small reddish clot in one of them. Vagina 5h inches wide : 
walls three lines thick, softened at its upper part. Bladder much distended ; internal 
surface irregularly red ; sub-mucous tissue of part corresponding to uterus infiltrated 
with reddish serum. 

Thorax.— Pericardium contains gij. of straw-coloured serosity. Heart of ordi- 
nary size ; black firm coagula in right ventricle ; walls one line thick; pulmonary 
va yes livid-coloured ; left ventricle contains two small blackish clots ; aortic valves 
pale, dorta pale, yet it contains some fluid blood. Pulmonary artery livid 
Lungs— Left: upper lobe perfectly healthy; slight engorgement and diminished 
consistence of inferior lobe; a few old adhesions posteriorly. Right: inferior and 
middle lobes more engorged than on left side ; pleuritic adhesions ; bronchi of lower 
lobe rather livid ; mucous membrane gives strips eight lines loner ; no fluid in either 
pleura. ° 



Case 87. 

anteflexion in early pregnancy. 

Mrs , set. 33, the wife of a medical man, in the first month of pregnancy, 

tell from a steep stair, the bowels at the time being exceedingly constipated. * There 
was no hemorrhage, but syncope continued nearly an hour. For six or seven weeks 

Mrs. _ was never entirely free from a heavy bearing-down sensation in front, 

rendering micturition frequent and painful; but defecation was not at all impeded. 
hhe was irrirab e and feverish, and it was thought by her husband that the womb 
was retroverted My first visit was at the end of the third month, and on exa- 
mining 1 found the cervix uteri in its natural position, but not so the fundus, which, in 
the form of a rounded and solid tumour, was lying forward between the anterior 
wall of the vagina and the bladder. She complained of pressure at the part where 
the oody was curved The cervix was elongated, fuller, and harder than natural, 
and the os open. I placed the fingers of my left hand behind the pubis, endeavour- 
ing in this wav to raise the fundus, while, with the forefinger of my rio-ht hand, I 
tried to draw the cervix downwards and forwards. I did not succeed, and no farther 
manual efforts were made An examination at the sixth month satisfied her hus- 
band that the curvature had nearly disappeared ; and although she was not, durino- 
the pregnancy, ever quite free from suffering, she was delivered without any diflf- 
culty, and recovered remarkably well. Care was taken that she observed the re- 
cumbent posture for a month For these remarks I am indebted to her husband, who 
is largely engaged in midwifery practice. 



418 DISPLACEMENTS OF THE UTERUS. 



RETROVERSIO UTERI. 

History. — Retroversion is an alarming, but a rare displacement, and 
when fully established, the altered position of the uterus is most striking. 
The fundus is turned downwards and backwards into the hollow of the 
sacrum; while the os and cervix are carried upwards and forwards, 
impinging on or lying above the symphisis pubis. It is the opposite of 
anteversion, and demands much more prompt attention ; for although 
at first, neither the function nor structure of the organ are affected, if it 
be overlooked or neglected, it will not be long ere extreme irritation 
and danger ensue. 

The disease was not unknown in early times ; as GEtius, Rod : a 
Castro, Mauricaeu, and La Motte described it, without affording an 
explanation of its nature. For our present more accurate views, we 
are indebted to Desgranges and Gregoire in France, and to our own 
distinguished countryman Dr. William Hunter. The former authors 
wrote in 1715 and 1746, the latter in 1754; and as the abridged ac- 
count of the first English case has become an interesting matter of 
medical history, I shall insert in a note Dr. Gooch's narrative of it as 
published in his lectures.* 

Causes. — It is almost entirely a disease of early pregnancy, and its 

* " A poor woman in London, about four months advanced in pregnancy, was sud- 
denly seized with retention of urine. She sent fur Mr. Walter Wall, a medical 
practitioner, who passed the catheter and relieved her ; but the impediment con- 
tinued, and it being again necessary to employ the catheter, Air. Wall, on this occasion, 
made an attentive examination, with a view to discover the nature of the obstruction. 
He passed his finger up the vagina, the course of which, instead of being upwards and 
backwards towards the sacrum, was up wards and forwards against the pubes. He 
could not feel the cervix uteri, but he discovered a tumour at the posterior part of the 
vagina, which, on the introduction of the finger into the rectum, was found to be be- 
tween the gut and the vagina. The lower portion of this tumour being projected 
toward? the pubes, the impediment to the evacuation of the bladder was supposed 
to be occasioned by its pressure on the urethra. Mr. Wall finding the case of his 
patient correspond with the description of retroversion of the uterus as given by 
M. Gregoire, endeavoured to replace the uterus, but without success. He then sent 
for Dr. William Hunter, who, upon examination, found the relative state of the parts 
to be that which has been just described. On raising the tumour the urine drib- 
bled away ; Dr. Hunter endeavoured to restore the uterus to its natural situation, 
but failed ; there was obstinate constipation, and in a few days the patient died. On 
examination after death, the bladder was found distended, the cervix uteri was turned 
upwards and forwards against the symphisis pubis, and the fundus had fallen down- 
wards and backwards into the hollow of the sacrum ; where it was so imparted as 
to be with difficulty dislodged. This case being the first of the kind which had 
been noticed in this country, excited great interest. Dr. Hunter gave a public lec- 
ture on the occasion over the body of the patient, in which he recommended punc- 
turing the membrane in order to procure abortion — a project which has never, hap- 
pily, been carried into effect. Another case of a similar kind occurred shortly after- 
wards; the patient could neither pass urine nor faeces. Attempts were made to 
empty the bladder by means of the catheter, but. without success : it was proposed to 
puncture the bladder above the pubes; the patient would not submit to this operation. 
At length she felt something burst, which proved to be the bladder, and in a few 
hours afterwards she died. The displacement of the uterus was found, after death, 
to be similar to that just described." — Gooch's Lectures, by Skinner, p. 117. 



DISPLACEMENTS OF THE UTERUS. 419 

most frequent cause is a distended bladder, which either gradually or 
under the influence of some sudden impulse, as cough, straining to 
void the urine, vomiting or a fall, pushes the uterus downwards and 
backwards, turning it, as it were, " topsy-turvy" into the hollow of the 
sacrum. A large pelvis, encroachment on the antero-posterior dia- 
meter of the brim by the sacral promontory, prolapse of the posterior 
wall of the vagina, early pregnancy, moles, pediculated and scirrhous 
tumours, affecting particularly the posterior wall of the uterus, and the 
condition of the womb after labour, have all been regarded as predis- 
posing causes. The published cases, however, are nearly silent on 
any other cause than pregnancy in connexion with a loaded bladder. 
Pearson and Dr. Blundell have seen the disease resulting from scirrhus 
and an enlarged ovary ;* and Dr. Churchill states, " that he has known 
retroversion happen the first day of a menstrual period, when the 
weight of the uterus was increased by the afflux of blood." These 
practitioners mention such examples, as the consequence of rare causes. 
Not so M. Lisfranc ; he says (p. 432), that " hypertrophy of the poste- 
rior part of the uterus is the most frequent cause ;" au assertion which, 
were it true, would establish a new fact (the great wish, probably, of 
itsauthor), viz., that retroversion is for the most part an affection of the 
unimpregnated womb ; for certainly pregnancy does not generally occur 
in connexion with such a degree of hypertrophy as would cause retro- 
version. But M. Lisfranc's statements are so often erroneous, that 
they rarely obtain any great respect or influence. May it not, however, 
have happened in some of his " hundreds of cases," that he has mis- 
taken the altered and fixed position of the womb produced by general 
hypertrophy or scirrhus, for retroversion ? I have been long in the 
habit of observing uterine organic disease ; and yet but a very few of 
the extraordinary things seen so frequently by M. Lisfranc have oc- 
curred to me. Nevertheless, his writings, the reader making the fullest 
allowance for his neglect of accuracy, deserve and will repay the most 
attentive perusal. 

* The following case by Dr. Blundell, p. 6, is too instructive and interesting not 
to be inserted : — °' 

' A lady, labouring under ovarian dropsy, was recommended to take a ride in an 
open carriage every day, for the improvement of her health, taking the air as much 
as might be without occasioning much fatigue. In one of these excursions, the vehi- 
cle chanced to be turned over, and she was thrown out with violence, her' abdomen 
striking with great force against a stone that was lying by the road side. On her 
return home, a very copious secretion from the kidneys ensued, with great abdominal 
pain, when, in the course of a few days, she recovered, and found herself entirely 
liberated from the dropsy. Some time afterwards she entered into the married state, 
and died with an irreducible retroversion of the uterus, about the fourth month In' 
spection was made, when it appeared clearly, that in consequence of the fall there 
had been a rupture of the ovarian cyst, and a flow of water into the peritoneal sac 
whence it was absorbed and effused by the kidneys, the remains of the cyst falling 
on the uterus, and carrying it down below the promontory of the sacrum, which be- 
coming retroverted, was fixed by the inflammatory adhesion in the retroverted posi- 
tion. While this unhappy lady remained unmarried, she felt but little inconvenience, 
but marrying, and the enlargement of the uterus taking place, the womb, in conse- 
quence of adhesion, not admitting of replacement, a fatal pressure of the contiguous 
parts ensued." ° 



420 DISPLACEMENTS OF THE UTERUS. 

Symptoms. — Retroversion is not at the moment of its occurrence, 
except it happen very suddenly, indicated by any marked change in 
the patient's state or feelings ; she generally remains ignorant of the 
accident till an attempt is made to relieve the bladder. Failing in this 
she becomes alarmed, and uses straining efforts, but is unable to accom- 
plish the act. The distention and the inability continue to increase ; 
for the renal secretion is not checked, and in twenty-four hours, if the 
catheter be not used, the suffering will be extreme. 

Another prominent symptom is pressure on the rectum, accompanied 
with a sense of weight and closure, so that the gut is difficultly, if at all 
emptied. Some watery stools and flatus pass, but no solid feculent 
matter. If some time elapse before medical aid is obtained, the state 
of the patient will be truly distressing. She may be advanced nearly 
four months in pregnancy ; she has a painfully distended bladder, with 
inability to void its contents ; and the rectum so obstructed by the ute- 
rine tumour, that its functions also are almost entirely suppressed. 

It cannot be supposed that such a state will continue long without 
the accession of formidable symptoms. As vesical distention is, at the 
commencement of the disease, the most distressing and prominent 
symptom, the catheter ought to be introduced once at least, if not 
twice, in the twenty-four hours : nor must it be forgotten, that although 
in ordinary cases the female catheter exceeds the urethra in length, in 
retroversion, this canal is so elongated by being carried upwards and 
forwards towards the symphisis pubis, that the common instrument 
scarcely reaches, and cannot enter the bladder. Thus a patient may 
be left, after supposed introduction, with the viscus enormously dis- 
tended. Under these circumstances, an elastic male catheter must be 
used. The fundus of the bladder in neglected cases of retroversion, 
forms a prominent and painful tumour, extending, when very full, not 
only just above the pubes, but nearly to the umbilicus, and reaching 
almost from one ilium to the other. In a hospital patient (Case 88), 
the bladder was so loaded, containing eleven pints of ammoniacal 
urine, that it occupied the whole of the abdominal cavity. Even where 
it is carefully emptied, there will often be an involuntary oozing of 
urine, which, bypassing over the parts, keeps them uncomfortably wet, 
and produces excoriation. 

But the bladder is not the only organ whose functions are interfered 
with ; the rectum is so pressed upon by the fundus of the uterus, that con- 
stipation, and sometimes almost an entire suppression of stools, ensue. 
These suspensions of the functions of the bladder and intestines, are not 
onl\ painful in themselves, but they aggravate the retroversion by the 
pressure of the accumulated urine and faeces above the displaced organ, 
forcing its fundus lower in the hollow of the sacrum, and giving to its 
cervix a still more elevated position above the symphisis. 

Nausea and vomiting are frequently present, and the feeling of pain- 
ful fulness in the pelvis, dragging from the loins, and expulsive pains 
like labour, increase the patient's sufferings. There is soon loss of 
appetite, stomachic and abdominal pain, fever with a quick pulse, hot 
skin and great restlessness. The action of the intestines is said to be 
sometimes, although rarely, inverted, stercoraceous vomiting being the 



DISPLACEMENTS OF THE UTERUS. 421 

result ; and Dr. Blundell possesses a preparation which shows the re- 
troversion of the uterus with disruption of the bladder.* 

Capuron (Mai. des Femmes, p. 286) remarks, " that if just so much 
urine escape as will prevent this frightful termination, the patient's life 
may be compromised by the fever, or ultimately by inflammation of the 
uterus and gangrene." 

Diagnosis. — Sudden retention of urine is a valuable diagnostic symp- 
tom ; but it is not conclusive. It is by examination only, that this 
formidable disease can be distinctly made out. 

The vesical tumour has been to my own knowledge mistaken for 
ascites ; but a vaginal examination and the catheter would have pre- 
vented such an error. 

There is more excuse if the pelvic tumour were mistaken for an 
ovarian enlargement; but the suddenness of the accident, and the 
peculiar form and situation of the tumour, will generally preclude even 
this error, f 

It cannot be difficult to distinguish a retroverted uterus from tumours 
growing in the recto- vaginal septum. Its form, its connexion anteriorly 
with the cervix, and the location of this latter part within the vagina, 
will prevent mistake. 

From the symptoms already detailed, especially the retention of urine 

* "The uterus is as large as a child's head ; above the retroverted uterus is the 
bladder, which has been ruptured. It is remarkable, that in this rupture of the blad- 
der, which has arisen from its over-distention, it is not the front, that surface of it, 
1 mean, which has no peritoneal covering, but it is the posterior surface, invested 
by the peritoneum, the back part of the body, which is the region of the rent. Now 
it was this which first led me to propose, that where a rupture of the Madder takes 
place in any case, but especially in a retroversion of the uterus, we should not give 
the patient up for lost ; for if there is reason to believe that the bladder is burst into 
the peritoneal sac, we might make an opening into the peritoneum — say above the 
symphisis pubis, by which we might discharge the urine, and then injecting distilled 
water of the temperature of 98°, we might wash out the viscera, so, perhaps, as to 
prevent a genera] peritonitis ; this done, we might draw the bladder up to the open- 
ing in the abdomen, and close the rent by ligature. This operation I have per- 
formed on several rabbits ; in one or two experiments I brought the bladder out, tied 
it up, and took away about one-quarter of it, viz., the whole of the fundus, and the 
animal did perfectly well. This operation I have never had occasion to try on the 
human subject ; but in a case otherwise desperate, I should be inclined to recom- 
mend it. I may remark here, that since I have suggested this method of closing 
the bladder by ligature, Mr. Travers has performed the operation on the stomach! 
There was a slight wound in the organ ; he boldly tied up the aperture ; the thread 
came away, and the case did perfectly well"— Blundell on Diseases of Women, p. 
19. Note. J ; v 

Dr. Marcet gives an example of retroverted uterus in the unimpregnated state, 
where constipation and vomiting were distressing symptoms.— Vide Cooper on 
Hernia, Part II., p. 60. 

f Nauche records a case which was supposed to be retroversion, and in consulta- 
tion about which, it was determined, as a last resource, to puncture the uterus, all 
efforts at reposition having proved unavailing. The patient died, and upon examina- 
tion it turned out to be a case of extra-uterine fcetation ; the sac containing the fcetus 
having descended into the pelvis. A fistulous communication had Taken place 
naturally between this tumour and the rectum. In such cases, a correct diagnosis 
must be very difficult of attainment ; happily they are very rare.— Mai Prop, aux 
Femmes, vol. i., p. 108. 



422 DISPLACEMENTS OF THE UTERUS. 

and the difficulty of defecation,* the former having come on suddenly 
and during early pregnancy ; from the situation of the cervix and the 
position of the fundus ; from the distressing pelvic fulness and the con- 
stitutional sympathies : from the constantly recurring necessity for the 
catheter ; and from the fact that in raising the tumour after emptying 
the bladder, it assumes the situation of the uterus ; — from all these 
indications combined, the nature of the disease may usually be deter- 
mined with certainty. 

Treatment and Termination. — All writers agree, that the uterus may 
right itself after the bladder has been emptied and the bowels freely 
evacuated. Such cases are recorded ; and doubtless there have been 
instances where the disease, never having been suspected, was thus 
spontaneously cured. Much, however, must depend on the retroversion 
being slight, and on these measures having been early adopted ; for the 
mechanical impediment to reposition is too great to allow the expecta- 
tion of so fortunate a result, where the displacement is complete and of 
long standing. 

Hunter and Denman, especially the former, did not think so seriously 
of the difficulties of reposition or of the dangers of continued retroversion, 
as we do now. In Dr. Hunter's remarks on Mr. Wall's case, he says, 
" after the case was suspected from the suppression of urine, and then 
certainly known by the examination with the finger, both in the vagina 
and the rectum, the urine was first completely drawn off by the catheter, 
then a sufficiently stimulating clyster was thrown up ; and after the 
bowels were well emptied, it was always found easy to replace the 
uterus. In one instance, the uterus of itself recovered its natural situa- 
tion, immediately after the above-mentioned evacuations had taken place. 
In another case, there were several relapses before the uterus grew so 
large, that it could no longer fall back." 

Burns coincides in these views, and counsels delay and confidence 
in the tendencies to reposition characteristic of advancing pregnancy. 
After mentioning the importance of evacuation of the urine, the employ- 
ment of injections to empty the bowels, blood-letting if there be fever, 
and of an anodyne clyster if there be strong bearing-down efforts, he 
remarks, " this is, in general, all that is requisite ; and as I wish particu- 
larly to inculcate the necessity of directing the chief attention to the 
bladder, which ought to be emptied at least morning and evening, or a 
gum catheter may be left in the bladder. By this plan we generally 
find, that the uterus resumes its proper situation in the course of a short 
time, perhaps in forty-eight hours ; and the retroversion is seldom con- 
tinued for more than a week, unless the displacement have been very 
complete. The precise time, however, required for the ascent of the 
womb will be determined, casteris paribus, by the degree to which it has 
been retroverted, and the attention which is paid to the bladder. If 
the fundus be very low, the ascent may be tedious ; but I consider 

* Burns says (8th edit. p. 259). that it has been maintained by some, that no effect 
is produced on the rectum ; nevertheless, the obstruction in certain cases is so great, 
that feculent vomiting is produced; and, moreover, on dissection, the rectum has 
been found stretched over the fundus uteri. 



DISPLACEMENTS OF THE UTERUS. 423 

myself as warranted from experience to say, that in every moderate 
degree of retroversion, in every recent case, it is sufficient to empty the 
bladder regularly without making any attempt to push up the womb. 
But if the uterine tumour be very low, and near the perinaeum, it may 
be necessary, and certainly it is ailowaole, to endeavour to replace the 
womb. This is also proper, if there be much irritation excited by the 
state of the womb, and which does not give way to the use of the 
catheter, and of anodyne clysters. I fear, however, that these efforts 
are too keenly made, and that often more harm than good is done by 
them. It may be said, that although the immediate danger be done 
away by the regular use of the catheter, yet the womb may remain for- 
ever in its raal-position, and give rise to great difficulty in labour, or to 
the same event as in extra-uterine pregnancy. I can only reply, that 
in almost every instance where the bladder has been regularly emptied, 
the case has done well ; and I do believe, that in those where the 
uterus did not rise spontaneously, very little good could have been done 
by mechanical efforts." 

Other opinions might be adduced in support of these views, and 
there are not a few instances where spontaneous reduction has followed 
the irequent employment of the catheter. Nor is this to be wondered 
at, if we remember that the bladder has sometimes, from accumulation 
of its secretion, equalled the size of a pregnant uterus of the sixth 
month. Here the prompt abstraction of many pints of urine, by which 
great pressure is suddenly removed from the wound, might permit in- 
stant replacement. Hunter mentions an example where the reduction 
occurred immediately after the bladder was thus emptied ; and in Mr. 
Croft's second case, the water having been drawn off for six days, the 
uterus suddenly rose. Dr. Cheston's case is very interesting ; a large 
accumulation of urine had taken place, and not being able to introduce 
the catheter, an attempt was unsuccessfully made to reduce the retro- 
version without drawing off the water. Had this been done, it is 
highly probable the bladder would have burst ; but, happily, the 
attempt failed. The bladder was then tapped (an operation, in the 
necessity for which, from all I have seen, I do not believe), and the 
uterus righted itself. No fact can more strongly attest the importance 
of relieving the bladder. A careful perusal, indeed, of the cases of re- 
troversion published by different authors will show, that where dealh 
ensues, it is usually either by irritation, by inflammation involving the 
peritoneum, or by rupture and sloughing of the bladder.* 

* Br. Hunter described a case, where the bladder after death was found to be ama- 
zingly distended, but not ruptured. Here, probably, death occurred from irritation 
and inflammation. — Med. Obs. and Inq., vol. iv., p. 400. 

Mr. Wilmer found the belly greatly distended ; six pints of urine were drawn off, 
but the woman soon died. The bladder, from disease of its surface (ulceration I pre- 
sume), contained a quantity of coagulated blood, and (he inflammation had spread to 
the colon. In this case the umbilicus was protruded like half a melon, and the dis- 
ease was at one lime taken for hernia. The uterus was found to be so firmly wedged 
in the pelvis, that it could not be raised up till the symphisis pubis was sawed avv°ay. 
— Wilmer s Case, p. 284. 

Mr. Lynn adduces an example, where the bladder burst, and immediately after- 



424 DISPLACEMENTS OF THE UTERUS. 

With these facts, and many others of the same kind might be 
adduced, it has always been to me a matter of surprise, that so little 

wards the woman miscarried ; but the uterus after death was found to be still dis- 
placed— Med. Obs. and Inq., vol. v , p. 388. 

Dr. Ramsbotham, Sen., was requested to visit a patient at Mile End, who had not 
passed her urine voluntarily for three weeks, but an involuntary dribbling had occa- 
sionally taken place without giving 1 her any relief. The vesical tumour^was large 
and painful, and her sufferings were relieved by the drawing off a large quantity of 
fetid offensive urine. Retroversion was detected, and she was four months advanced 
in pregnancy. The catheter was daily introduced, and aperient medicine administered. 
Within ten days, two unsuccessful attempts at reduction were made. Towards the 
end of November (1817), Dr. Ramsbotham having first seen her October 3d, as there 
was costiveness, nausea, occasional vomiting, and much emaciation, made another 
violent effort to replace the womb, but did not obtain his object. On the evening of 
December 14th, labour commenced, after the discharge of the liquor amnii. The 
pelvis was completely filled up by the enlarged uterus, with the os uteri open above 
the brim, pressing against the abdominal parietes, through the emaciated structure of 
which the hand could distinctly detect the opening uterine mouth. Dr. R. now de- 
termined to make another and very active attempt at reduction. Kneeling down by 
the side of the bed, he introduced the whole of his left hand into the rectum, then 
passing his right hand between the thighs upon her belly, he pushed up the fundus 
uteri with the palm cf his left hand, at the same time drawing down the cervix and 
parts adjoining with his right hand. This was successful ; a living child was born 
in about two hours, and the mother ultimately recovered her previous state of 
health. Dr. R. thought that the reposition was attributable to the sudden diminu- 
tion of uterine bulk by the discharge of the liquor amnii, a fact he says, " that may 
lead to future improvement in practice in cases of danger." — Pract. Obs., Part II , 
p. 541. 

In another case, the patient had suffered " under the extreme agonies of a distended 
bladder for fourteen days and nights, the bladder beino prevented from bursting by 
the droppings mechanically forced out of the urinary passage by the degree of disten- 
tion." The symptoms were alarming, and having made two powerful aTid unsuccess- 
ful efforts at reposition, Dr. Ramsbotham, with great difficulty, punctured the mpm- 
branes,a four months' fcetus being expelle'd two days afterwards. I have quoted this 
case because in this lady's subsequent pregnancy, the uterus, at the third month, be- 
came again retroverted ; but, '• after the bladder had been relieved a tew times by the 
catheter, the uterus spontaneously righted itself, without the necessity of other assist- 
ance."— Pract. Obs., Part II., p. 443. 

In a third case, retroversion occurred from an attempt " to reach something from a 
shelf," producing a sensation of a giving way within her, which was followed by an 
inability to pass urine; yet a little escaped now and then involuntarily. Three quarts 
were drawn off; it was highly offensive and loaded with mucus, the pulse was quick 
and irregular, countenance pallid, showing marks of great anxiety. A day or two 
afterwards Dr. R. recommended the induction of prernature labour; but no persua- 
sion could induce the patient's assent. She lingered in a state of extreme suffering 
to the time of her death, May 7th, a month after the retroversion, it was found on 
a post-mortem inspection, that the bladder was large and flaccid, its peritoneal 
coat exhibiting marks of inflammation, and its mucous lining covered with a sub- 
stance of a semi-fluid consistence. When this was removed, its internal surface 
was rough, floccnlent, and the whole vesical contents were extremely offensive. 
At the point of adhesion between the bladder and colon, the ulcerative process had 

taken place, so that there was a free communication between the two cavities 

P. 440. 

Dr. Squires relates an instance in the Medical Review for 1801, in which the blad- 
der gave way ; and Dr. Ross (Annals of Med., vol. iv„ p. 248) gives the details of a 
patient, who, after the uterus was reduced, aborted and died; the bladder beina found 
thickened and adhering to the navel. 



DISPLACEMENTS OF THE UTERUS. 425 

anxiety should be evinced about reposition. If the uterus be procident, 
a far less serious accident, its immediate return is always advised ; and 
we blame the practitioner who allows any unnecessary delay. Jn retro- 
version, a disease of present and daily increasing danger, we are advised 
to content ourselves with drawing off the urine and emptying the 
bowels: the former, it is true, removing weight from the displaced 
womb ; but the latter, necessary as it is for safety, enlarging the space 
for more complete retroversion. Nay more, Burns and Merriman, able 
and distinguished practitioners, seem to look almost with calmness on 
the great evils of repeated and only partially efficient introduction of 
the catheter ; seeming to forget what the recorded cases prove, that 
however carefully the catheter may be employed, it is next to impos- 
sible, as the retroverted uterus is growing daily, its contents being still 
possessed of vitality, that the bladder shall be fully emptied. It is 
not difficult, therefore, to understand, when these gradual accumulations 
are going on for many weeks, that the mucous surface of the viscus 
shall become chronically inflamed, and that eventually purulent and 
sanguineous urine shall attest that dangerous ulceration has occurred. 

Burns remarks, "it is nevertheless possible for the uterus to continue 
in a certain degree of mal-position, even to the end of gestation. Af- 
terwards, as though it were not very injurious that it should do so, he 
observes, "in this case the uterus cannot, indeed, at last be said ex- 
actly to be retroverted ; for it has enlarged so much, that it occupies 
nearly as much of the abdomen as usual," and he should have added, 
what constitutes the great danger, that it is wedged into and entirely 
fills the pelvis also. 

Dr. Merriman and Dr. Barnum's cases,* and there are other similar 
ones, are not encouraging examples of the practical safety of these 
views. I believe, if in every case of retroversion, whether occurring 
before or after the third month, reposition was at once attempted, there 
would be but few cases of failure. f 

" Mrs. F., being about five months pregnant, was suddenly terrified, and felt as if 
her inside were turned upside down. The symptoms, however, were not very acute, for 
she voided the urine in the last month of gestation, though with pain and some diffi- 
culty. On the 16th of June she had some pains, and a discharge of serous fluid ; no os 
uteri could be felt, but a large semi-globular tumour on the back part of the vagina, 
bearing down toward the perinseum. The pains brought on fever, and at last delirium 
and convulsions. She was bled, and had a clyster, after which she got some sleep, 
and the pains continued moderate, though regular, for two or three days, and she passed 
both urine and stools. On the 20th, nothing like os uteri could be felt ; but on the 
21st, there was perceived a thick flattened fleshy substance descending into the 
vagina, and very soon the uterus was restored to its natural situation. ^The sub- 
stance was found to be the scalp of the child, containing loose bones. The child 
and placenta were delivered, and the mother recovered. 

Dr. Barnum relates, that the patient, in the fifth month, after some imprudence, 
had pain accompanied with a discharge of water and some blood. In the following 
month, November, she had a return of pain, and the os uteri was felt directed to 
the pubis, and the fundus to the sacrum. All attempts to reduce it failed ; suppura- 
tion took place, and foetal bones were discharged by the anus. She died in March. 
— Med. and phys. Jour, vol., xvi., p. 388. 

f In 1840 1 was requested to see a young woman four months pregnant. Nearly 
a fortnight before, soon after jumping over a flower-pot in the garden, she found she 



426 DISPLACEMENTS OF THE UTERUS. 

Dr. Dewees thinks, " that an exclusive reliance upon drawing off 
the water, has been productive of the most serious evils, if not in some 
cases of death itself." 

Even where powerful, and according to Dr. Ramsbotham, " violent" 
efforts have been used in attempting reduction, neither " delirium nor 
convulsions" have ensued ; both of which occurred in Dr. Merriman's 
case, where the displacement continued up to the time of labour. It is 
indeed almost impossible to imagine a more dangerous complication of 
miseries than that resulting from retroversion persisting to the end of 
pregnancy. Nothing short of the absolute impossibility of reduction 
can justify the abandonment of the patient to such a fate. The risk of 
producing abortion, and the occasional difficulty of replacement, are 
certainly evils; but of far less magnitude than delayed reposition, wilh 
its accompanying and certain dangers. 

The methods of reduction are not entirely the same, either as to 
position or the means employed. In cases where the patient is seen 
early, the usual obstetric posture on the left side, and close to the edge 
of the bed, may be adopted. After drawing off the water, all the 
fingers of the right hand should be passed into the vagina, over the 
body and fundus of the womb, while the thumb, inserted into the rectum, 
places the retroverted uterus favourably for reduction. Gentle pressure 
will often suffice for its restoration. But the attempt to reduce the re- 
troversion in this way is not always successful. The patient may then 
be placed on her knees and elbows, so that the pelvis shall be higher 
than the abdomen, thus removing the pressure of the viscera. Two or 
three fingers of the right hand are to be passed into the rectum, so as 
to get a bearing on the fundus, w T hich is to be urged above the promon- 
tory of the sacrum ; and if at all practicable, two fingers of the left hand 
may at the same time be placed on the cervix, and while pressing the 
fundus upwards, we may draw the os downwards. I know r how diffi- 

could not pass her urine. She strained violently, sat over hot water, and applied 
gin fomentations, hut all without effect. A neio-hbourincr practitioner discovered the 

o C o i 

retroversion, drew off the water, gave an aperient, but did not attempt reposition. 
The symptoms grew daily much worse: the use of the catheter was attended with 
great suffering, and was alwa}'s followed by the passage of purulent matter, and 
frequently of blood. Defecation could only be effected by active purgatives, for it 
was impossible to inject a clyster. The pulse was quick and compressible, there was 
constant nausea and frequent vomiting. What was to be done? 1 urged immediate 
reduction ; but the attendant practitioner recommended still further delay, express- 
ing a wish that, after the use of the catheter, she should lie on her abdomen to aid 
spontaneous replacement. To this, most unwillingly. I was compelled to assent. 
Two days elapsed, brino-ipcr with them not the reduction, but acraravated sufferings. 
My first attempt was unsuccessful ; on the next occasion, with as little severe pres- 
sure as possible, 1 got nearly the whole of my right hand into the rectum, while 
with the fingers of my left hand I tried to reach and press upon the cervix. In less 
than a quarter of an hour, or very little more, 1 succeeded. The patient, although 
complaining of the process, declared the suffering was nothing in comparison with 
what she had endured the previous three weeks. There was no amelioration to be 
hoped from palliative measures; everyday would have accumulated difficulty and 
suffering; and at length, long before the term of pregnancy had expired, either 
puncturing the membranes or tapping the uterus must have been resorted to. 

1 have appended this cast in the form of a note, as illustrative of the opinions ex- 
pressed in the text. 



DISPLACEMENTS OF THE UTERUS. 427 

cult it is to execute the latter part of this duty, for in using both hands 
so close together, one necessarily embarrasses the other. It is sometimes, 
too, impossible to reach the cervix; and even when touched, 'it may 
be so slippery from mucus, that we cannot retain our hold. 

In extremely bad cases of retroversion, where perhaps more than four 
months of pregnancy have elapsed; where every attempt at reduction 
has shown the womb to be almost immovably wedged in the pelvis, 
bleeding, the exhibiiion of tartarized antimony, so as to induce nausea,' 
and the warm bath, are valuable adjunct remedies. U\ when these' 
have produced their effect, the bladder and rectum being also evacuated, 
we make another and more powerful attempt, we may succeed; nor 
ought we, till having failed in repeated efforts, determine that reduction 
is impracticable. For my own part, I have so great a dread of the 
continuance of retroversion, that I would not hesitate to introduce the 
whole hand into the rectum, and exert very considerable power to ac- 
complish this desirable object.* Baudelocque expresses the following 
opinion : " We can say nothing here of the force necessary for replacing 
the uterus. Sometimes very little is necessary, if well directed; at 
other times we must use a great deal. The fear of provoking an abor- 
tion in the latter case, ought not to check the operation. Besides that 
it is not always the consequence of such efforts, for I could quote more ' 
than twenty cases in support of this assertion, the danger to which re- 
troversion exposes both mother and child, will be much greater and 
more certain, if that viscus be not replaced in time." 

No practitioner conversant with operative midwifery, can fail to ap- 
preciate the difficulty of determining the exact degree of power (for I 
do not like the word "force") which should be used in turning 
cases and deliveries by the forceps; for while, on the one hand, it is 
imperative that no greater power should be exerted than is absolutely 
necessary; on the other, it is equally imperative that the utmost effort, 
compatible with the safety of the soft parts, should be used to insure 

: On T uly 8th, 1834, I wa^ called to Airs. T.. who had, from being knocked down 
by a drunken husband, suffered retroversion of the uterus in the 14th week of her 
pregnancy. • The accident occurred five days before I saw her, and she had not since 
relieved the bladder by more than a few drops at a time. I drew off the water (nine 
pints), and in the course of a few hours the bowels were evacuated for the first time 
since the accident. My first attempt at reduction was unsuccessful, for I could not 
move the fundus; and on two other occasions I was equally unfortunate. Findino- 
that sue became impatient and exceedingly averse to the catheter, which a neigh- 
bouring practitioner, the late Mr. Ranee, of the City of London Lyino-in Hospital, 
used for her, and that her sufferings were producing fever and great excitement, I 
determined to make a final and powerful attempt at replacement. As the pulse 
wasqu.ck and hard, we took away twelve ounces of blood, which induced slight 



w placed on her knees and elbows, Mr. Ranee sitting by her 
ition. Having lubricated my right hand, its introduction into 



syncope. She was now 
to keep her in this pos 

the rectum was gradually accomplished, and with "much les7'p7in1o , 'ihe 'orient and 
difficulty to myself than I could have supposed. 1 soon found that I had Ueat com- 
mand over the tumour, and Mrs. T. exclaimed, on powerful pressure bein* made 
upon it, '• that the womb was going into its place." There was, however, considerable 
delay in g ttmg it past the promontory of the sacrum ; but in about fifteen or twenty 
minutes from the first effort, it passed fairly out of its wedged position in the hollow 
of that bone. She was requested to keep in bed for a fortnight, and to avoid all vio- 
Jent exertion. She went to her full time, and was safely confined. 



428 DISPLACEMENTS OF THE UTERUS. 

the completion of the labour. Just so in the reduction of a retroverted 
womb. A timid practitioner, dreading the consequence of these great 
exertions of power, often wastes time in slight and ineffective attempts 
at reduction; whereas efforts of a more decided character would lead 
to replacement. It has been recommended, where it is difficult to pass 
the finger beyond the cervix in order to depress it, that a pair of hooked 
forceps should be used. Such an instrument could not be easily carried 
to its destination ; though if we were so far successful, it might aid the 
reduction. Duges urges the introduction of a sound into the bladder 
to depress the neck ; but I am not aware that this suggestion has ever 
been tried ; nor, can I imagine that any efforts to alter the position of 
the cervix will avail much, unless they are simultaneous with an at- 
tempt to raise the fundus, the serious part of the disease. 

But if, after all our efforts it is not possible to effect reposition, two 
methods of procedure are still open. Either we may leave the case to 
nature, sedulously attending to the bladder and rectum, and wait till 
labour spontaneously occurs ; or we may induce premature parturition, 
by puncturing the membranes through the os, or by tapping the uterus 
through the vagina or rectum. * Sufficient objections have, I think, 
been already urged against the first course; but if it be determined on, 
the recommendation of Denman ought to be followed. It consists in 
allowing but little liquid, keeping the bladder thoroughly emptied, by 
the use of the catheter two or three times a- day, and in maintaining, for 
hours together, an inverted position of the pelvis, by placing the patient 
on her knees and elbows. Dr. Blundell, who has much greater confi- 
dence than I have in this treatment, says, " she is not merely to give 
way on account of fatigue, but to continue it as long as the replacement 
may require. Adopting this plan, the bladder being empty, the womb 
will sometimes return to its natural position ; may be immediately, may 
be an hour or hours, but I think I may venture to add, that it pretty 
certainly returns at last." It would have been satisfactory and convin- 
cing, if cases proving the success of this measure had been recorded. 
In their absence, it may be doubted whether this gentler expedient 
ought to be relied on^ when w T e know the great power which is often 
required to dislodge the fundus in protracted retroversion. 

It has been found sometimes, although seldom, that the catheter 
could not be passed ; and, as already seen in Dr. Cheston's case, the 
bladder has been tapped prior to any renewed attempt at reduction. I 
cannot see how such insuperable difficulty should exist, and in this 
opinion Burns, Dewees, and many other practitioners coincide. A pe- 
rusal of the cases where reposition was most difficult, owing to the size 
the uterus had attained and the degree of vesical distention, wdll show, 
that even in these, the flexible male catheter was introduced without 
any marked delay or suffering. 

* Dr. William Hunter was the first to suggest this practice (Med. Obs. and Inq., 
vol. iv., p. 106). "• Would it not," he asks, " be advisable, in a bad case, to perforate 
the uterus with a trocar, in order to discharge the liquor amnii, and thereby render 
the uterus so small as to admit of reduction 2" It does not, however, appear that it 
has been done more than twice, once on the Continent and by Mr. Baynham at Bir- 
mingham. 



DISPLACEMENTS OF THE UTERUS. 429 

It is not always easy to puncture the membranes through the os, 
owing to the elevated position of the cervix ;* and if we fail in repeated 
attempts to accomplish this purpose, tapping the uterus is our only re- 

* "Not being at the moment provided with any proper instrument for rupturing 
the membranes, I deferred the operation till the evening; when I attended with 
such means as seemed likely to accomplish my intended object. After drawing off 
the urine, which was still mixed with a quantity of fluid blood, I passed two fingers 
of my left hand by the pubes upon the os uteri, over which I introduced a bending 
bougie, and was fortunate enough to insinuate its point within the os uteri, by which 
the membranes were ruptured." — Dr. Ramsbotbam' > s Prac. 06s., vol. ii., p. 446. 

"In a case of retroversion of the uterus, where the catheter could not be intro- 
duced, nor the rectum emptied, I should feel myself inclined to consider the pro- 
priety of tapping the uterus, which might perhaps be found, on the whole, to be as 
desirable an operation as tapping of the bladder, or the dividing of the symphisis 
pubis. I should not take a great trocar and canula, as if I were going to tap in a 
case of ascites, wounding a great many vessels, and perhaps occasioning death ; but 
I should prefer an instrument of a very small size, by which I could perform a sort 
of acupuncturation. Perhaps an instrument on the principle suggested might be 
introduced into the uterus without much danger ; and then, if a contrivance were 
fixed upon the other end of it, so as to bring away the fluid by a sort of suction, it may 
be that a good deal of the liquor amnii might be drawn off. If the uterus was thus 
evacuated of the liquor amnii, there would immediately be a considerable reduction 
of its bulk, and perhaps at length an expulsion of the ovum. The womb might be 
tapped either from the vagina or the rectum; but vaginal tapping would, I conceive, 
be preferable. — Blundell on Diseases of Women, p. 15. 

Mr. Baynham says, "The consequences of retroversion of the uterus have been so 
often fatal, that a case successfully treated by surgical operation cannot be devoid 
of interest. The practice adopted in this instance will be found uncommon; and, 
since it led to a successful issue under the most unpromising circumstances, deserves 
to be recorded. 

" Hannah Martin, age 30, of spare make, was admitted a patient of the dispen- 
sary, 28th of March, 1828. She was then in the sixth month of her second preg- 
nancy, the history of her case to which period is briefly as follows : — 

" When employed six weeks previously in moving a heavy weight, she suddenly 
felt acute pain in the lower part of the belly. To this, however, little importance 
was attached at the moment. Two days afterwards retention of urine occurred with 
almost constant pain. The nature of the case appears to have been overlooked by 
the gentleman consulted in the first instance, since the use of the catheter was not 
proposed. She had dripping of urine, with progressive enlargement of the abdomen 
during the next month ; at the end of which time, finding no relief in medicine, she 
applied to another surgeon, who, by the introduction of a catheter, obtained eight 
pints of urine in the morning, and nearly the same quantity seven hours afterwards. 
No examination per vaginam was even now instituted, and, of course, no perma- 
nent relief secured to the patient, the catheter only being used night and morning in 
the next fortnight. When recommended to the dispensary she°had kept her "bed 
three weeks, and was in a state of high fever, her pulse 136, short and indistinct. 
She had frequent vomiting, constant micturition, tenesmus, fulness, tension, and 
tenderness of the abdomen. In my first attempts to pass a catheter, I was embar- 
rassed by the altered state of the external organs; a large portion of the vagina being 
prolapsed, and the clitoris and nymphae greatly enlarged. The urine which escaped 
by the instrument resembled the contents of a psoas abscess, but was much more 
fetid. The entire cavity of the pelvis was occupied by a tumour which caused pro- 
trusion of the anus, and also eversion of the lower extremity of the bowel. The 
mouth of the uterus was far beyond the reach of the finger, and the fundus of this 
organ was situated less than one inch from the anus, — a circumstance which ren- 
dered the admission of the finger into the rectum, a work of much difficulty. Feel- 
ing satisfied that no urine remained in the bladder, I attempted to replace the uterus 
by a gradual introduction of the whole hand into the vagina. The os uteri pointed 
directly upwards, and was raised above the pubis; in°fact, the retroversion was 
complete. 

28 



430 DISPLACEMENTS OF THE UTERUS. 

source. The extreme suffering will not often allow us, even were we 
disposed, to content ourselves with drawing off the water and palli- 
ating symptoms to the time of labour. Dr. Blundell's views of the me- 
thod in which the operation should be performed, and Mr. Baynham's 
most interesting case, I have inserted in the notes. 

"Having persevered as long as seemed consistent with the safely of the patient, 
I requested the attendance of two of my colleagues, and they met me in consultation 
the same afternoon (March 28). She had hecome much more exhausted and rest- 
less. Her anxiety of manner, and the failure of her pulse, leading us to suppose 
that she was nearly moribund, I proposed the immediate introduction of a trocar into 
the uterus for the purpose of lessening its volume. Preparatory to any other steps, 
the catheter was again used, and having then placed the woman upon her elbows 
and knees, I once more endeavoured to raise the tumour, but not succeeding better 
than before, I slowly passed my hand into the rectum, and, adapting it as faAis pos- 
sible to the base of the tumour, continued for some time to make the firmest pressure 
without sensible advantage. 

"Mr. Blount, one of the gentlemen present, in the expectation of a better" result, 
desired to satisfy himself of the impracticability of success before the operation of 
puncture was adopted. Having passed his finger into the os uteri, he endeavoured 
to rupture the membranes; but, although assisted by a curved metallic instrument, 
he was compelled to relinquish his purpose, and all other expedients to relieve 
the patient having failed, it was determined to employ the trocar. In this proceed- 
ing I selected the most prominent point of the tumour in the rectum. The entrance 
of the trocar not being followed by any discharge, it was withdrawn and introduced 
a second time in nearly the same situation. About twelve ounces of colourless fluid 
now escaped by the canula, but not without frequently changing its position ; since 
the opening was at times obstructed by the presence of the child. The fulness of 
the uterus having thus been diminished, attempts were again made to carry it above 
the brim of the pelvis, and this was effected in less than a quarter of an hour. 
When the organ had recovered its proper situation, the os uteri was found partially 
dilated, and the membranes somewhat protruding. A full opiate was prescribed, and 
the woman passed a better night than any in the previous month. 

"The next morning, although still in a state of great exhaustion, she was de- 
cidedly improved. Labour pains occurred in the evening of the 29th, and less than 
one hour sufficed, fortunately without hemorrhage, to exclude the contents of the 
uterus, twenty-five hours after the operation. The ovum was entire, the membranes 
perfect, and still retaining ten ounces of liquor amnii untinged with blood. The 
foetus was perfectly fresh, and of the ordinary size at six months. The trocar both 
times had penetrated the substance of the placenta near to the insertion of the cord, 
and once had entered the abdomen of the child ; forming an aperture through which 
nearly the whole of the small intestines were forcibly protruded by the pressure sub- 
sequently used. The second puncture was referable to this unavoidable accident. 
It is worthy of remark, that, notwithstanding the placenta was twice perforated, 
hardly a teaspoonful of blood was lost."— [In a case of Mr. Hunter's (July, 1844), 
of Tower Street, where 1 was consulted, and where it was, for the fifth time, neces- 
sary to bring on labour prematurely af the 7th month, the placenta was perforated 
five or six times, owing to its being over the mouth of the uterus, before we could 
succeed in satisfying ourselves that the membranes were really punctured. The 
liquor amnii escaped, however, and labour occurred. On examination afterwards, 
we found seven or eight perforations, but neither previously, during, nor after the 
labour, was there hemorrhage.] 

"The catheter was used but once after this time, when a pint of equally offensive 
urine was evacuated. Incontinence then supervened, and lasted nearly five weeks ; 
and severe pains continued to be felt in the pelvis for some time. Copious vaainal 
discharge, added to the stillicidium urinse, kept up a state of soreness and excoriation ; 
and it was not until after a month that her urine lost its foe tor. Considerable masses 
of coagulated lymph were often discharged, and, at separate times, four pieces of re- 
gularly organised membrane, which were mistaken for portions of the bladder, but 



DISPLACEMENTS OF THE UTERUS. 431 

Case 88. 

RETROVERSION TERMINATING FATALLY. 
REPORTED BY THE CLINICAL CLERK. 

n ^1; — T' *'• f 1 / was admittpd '"to Petersham Ward, under Dr. Ashwell's care, 
if I' ten children < and had miscarried three times For five 

months she had observed a progressive increase in the size of her abdomen, which 
she attributed to pregnancy; but there were no other corroborative symptoms. For 
three weeks previous to her admission, she had been mu6h annoyed by a constant 
stil hcidium urinae." Soon afterwards the swelling flhe abdomen increased more 
rapidly, attended with great pain in the back, and a dragging sensation at the um- 
bilicus : notvvithstanding, she daily passed a considerable quantity of water, occa- 
sionally or a high colour. The swelling of the abdomen was oviform, occupy in* its 
whole cavity, with a decided fluctuation on percussion, except at the upper part 
where an indistinct boundary could be felt: its surface was tense, shinini, and tral 
versed by distended veins. The pulse was quick, the countenance flushed, and the 
respiration hurried. During the first night after her admission, she passed two pints 
ot urine by the voluntary efforts. On examination per vaginam, the os uteri could 
not be found ; but a considerable gush of fluid of a urinous smell followed the intro- 
duction of the finger. Per rectum, a large tumour could be felt pressing upon and 
diminishing the calibre of that bowel. A long female catheter was now obtained ; 
but it was only after repeated solicitations and almost compulsion, that the patient 
would allow it to be passed ; its introduction was accomplished with great difficulty, 
as the meatus unnanus was drawn up above and behind the pubes. Upwards of 
eleven pints of ammoniacal urine were obtained ; after which, she was placed on her 
Knees and elbows, and the uterus was restored to its natural situation. In three hours 
the catheter was again introduced, when three pints more urine flowed away. On 
the following morning, four and a half pints more were evacuaied. From this time 
the catheter was obliged to be constantly resorted to, to relieve the weakened blad- 
der ; in the course ot five days she aborted of a three-months' foetus, and sank 96 
hours afterwards. 

I believe partial retroversion of the unimpregnated womb to be a 
more frequent occurrence than is generally supposed ; its most common 
cause being hypertrophy, or more serious disease of the posterior wall 
of the organ. If in such cases, where there is difficulty of micturition 
and defecation, a careful examination were made, the uterus would, I 
am persuaded, be often found more or less retroverted. The measures 
necessary for the cure of the morbid state of the uterine structure, will, 
if successful, be curative also of the retroversion. 

which subsequent events happily proved to be parts of the vagina only. At the end 
of April she had the satisfaction of holding small quantities of urine, and in a fort- 
night could retain it almost as well as before her illness. The rectum was lono-er in 
recovering its tone than the vagina; purulent evacuations taking place from the for- 
mer passage, with frequent and sometimes distressing tenesmus, until alter she was 
mother respects well. It is probable that an abscess formed in the cellular sub- 
stance, between the vagina and rectum, since the matter voided per anum was dif- 
ferent, and more in quantity than the mere surface of the bowel could have yielded. 
She kept her bed three weeks before she applied to the dispensary, and did not 
leave it until nearly a month afterwards. Upon the 7th of May, she was sufficiently 
recovered to leave home and engage in her usual occupation. Menstruation oc- 
curred in the first week of June, and she has continued in good health since that 
period."— Edm. Med. and Surg. Jour., March 1830, p. 256. 



432 DISPLACEMENTS OF THE UTERUS. 



RETROFLEXION OF THE UTERUS. 

I have already remarked, that there are practitioners who doubt the 
existence of this state ; and of late years, I believe many cases of slight 
and unimportant uterine displacement have been most erroneously set 
down as examples of the anterior or posterior flexion ; but that these 
affections really occur, I have not any doubt. To Levret we are in- 
debted for the first notice of anteflexion, and Denman, one of the most 
eminent and truthful practitioners, was the first to describe retroflexion. 
The former celebrated man communicated his views in 1773, in the 
old French Journal de Medecine, torn. 40, p. 269, treating of antever- 
sion " as a particular displacement of the uterus, not previously spoken of 
by authors." Denman (Introduction to Practice of Midwifery, chap. 4, 
sect. 2) defined the latter malady, " as such an alteration in the posi- 
tion of parts of the uterus, that the fundus is turned downwards and 
backwards between the rectum and vagina, whilst the os uteri remains 
in its natural situation ; an alteration which can only be produced by 
the curvature of the uterus in the middle, and in one particular state ; 
that is, before it is properly contracted when a woman is delivered. 
A suppression of urine existing at the time of delivery, and continuing 
unrelieved afterwards, was the cause of the retroflexion in the single 
case of this kind of which I have been informed by Dr. Thomas 
Cooper, and the symptoms were like those occasioned by retroversion. 
When the urine was drawn off by the catheter, which was introduced 
without difficulty, the fundus of the uterus was easily replaced by raising 
it above the projection of the sacrum, in the manner advised in cases of 
retroversion, and it occasioned no farther trouble." 

Thus retroflexion may be regarded as partial retroversion — the same 
in every respect save one— the alteration of position of the cervix; 
which, from its preserving its proper locality, renders curvature or 
flexion of the body necessary to the production of the displacement. 
Retroversion and retroflexion bear the same relation to each other in 
the posterior part of the pelvis, as anteversion and anteflexion do in its 
anterior space ; but the relation is destroyed, if we regard the more 
serious mischief produced by the latter beyond that which results from 
the former diseases. 

I need not occupy the time of the reader by a detailed history of 
retroflexion : its symptoms are in a great measure those of the related 
malady ; their cause and the treatment are nearly similar. It is easy to 
understand the improbability of its occurrence during pregnancy, at 
least after the earliest period ; for subsequently the general enlargement 
of the uterus would preclude the displacement of one portion alone. 
Denman's views, so far as they go, are correct, and I can readily under- 
stand how rare an occurrence it must be in the puerperal state ; but he 
was wrong in supposing it never occurred in any other condition. I 
have seen two well-marked cases, and in both the uterus was unim- 
pregnated. The details of these will probably furnish all the addi- 
tional information necessary for a correct appreciation of the disease. 



DISPLACEMENTS OF THE UTERUS. 433 



Case 89. 

w^ntZT^'iu 881 ^ 8 ' . reSi ^D ? in , l l e Country ' and the mother of several children, 
was placed by Mr. Crook, of Brook Street, under my care for some displacement of 

lilt? U LfcJ 1 lio* 

She complained of difficulty in defecation, and of frequent desire to pass water, 
especially during the night. There was much pain about the loins and sacrum, and 
a most distressing sensation of fulness and weight in the perinaBum. Aperients were 
frequently used, and even then, unless the contents of the bowels were liquid, she 
could scarcely empty the gut. The catamenia had been regular as to period but 

the discharge was scanty and painfully excreted. Mrs was evidently'suf- 

fering severely from this pelvic derangement; she was irritable and feverish ; passed 
sleepless n.ghts, and had scarcely any appetite. The pulse was quick, the tonaue 
furred, and I was informed by Mr. Crook, that her health had been gradually de- 
clining for many weeks. On examination, I found the cervix swollen, but in its 
natural situation ; or if at all changed, slightly projected upwards towards the roof 
of the vaama, immediately behind the junction of the neck with the body of the womb 
and the finger passed into a space, evidently formed by a curvature at an acute ano-le 
f !u 6 r Z organ; and below this and upon the rectum, the posterior p°art 

of the fundus was easily felt. On passing the finger into the gut a large, hard, 
rounded mass, the fundus of the womb, was at once distinguished ; but there was a 
considerable quantity of solid faeces in the bowel, evidently the consequence of incom- 
plete defecation I could not, on inquiry, ascertain any very definite cause for the 
displacement ; the only circumstance remembered, was difficulty in passing water 
two months before, after a long walk ; but she confessed, that subsequently, she had 
never been quite free from uneasiness, and that latterly she had frequent throbbing 
pain in the rectum. ^ ° 

A repeated examination convinced me, that there was at least considerable con- 
gestion of the whole organ, but especially of its posterior wall, if not inflammation, 
as the parts were hotter than natural and pressure was badly borne. Aperients, 
effervescent salines, and anodynes were exhibited ; the recumbent posture was en- 
joined, and the warm hip-bath was used night and morning for several days. At 
the expiration of this time, having placed her on her elbows and knees, I attempted 
to restore the fundus to Us natural state in the pelvis, but without any success. 
Ihese efforts were, however, continued daily for a week, at the end of which, havincr 
lain almost the whole time on her stomach, I was convinced the uterus had nearly 
reached its natural position. I was, however, too anxious to complete the replace- 
ment, to allow her to return home without another attempt. 1 used on this occa- 
sion a piece of sponge covered with soft bladder, mounted on a thick wooden stem : 
having oiled it thoroughly, I passed it very high up the rectum, and havino- used 

considerable power, Mrs. said she felt quite easy ; and on examining f found. 

to my great satisfaction, the uterus in situ. Soon afterwards the lady became aaain 
pregnant, wearing a pessary nearly the whole time. No untoward event occurred 
either during gestation or delivery. She has since died from consumption. 



Case 90. 

RETROFLEXION OF THE UNIMPREGNATED UTERUS. 

io^ RS *T > ffit - 3 0, married, but without children, called upon me, September, 

1844, at the request of Mr. Steel, a surgeon residing in Well's Street, Gray's Inn 
Road ; complaining of menorrhagia. Her symptoms induced me to request an ex- 
amination and from the rounded form, central position, and mobility of the cervix, 
at first I thought I was touching a polypus; but the error was instantly corrected, 
by carrying the finger towards the under surface of the cervix, when I found the body 
of the uterus curved at an acute angle on the cervix ; and as the fundus was fairly in 
the hollow of the sacrum, the finger could be easily placed in the angular space. By 



434 DISPLACEMENTS OF THE UTERUS. 

the rectum the uterine tumour could be distinctly felt, and I was sorry to find it was 
firmly fixed in its new situation ; for although firm pressure was made upon it from 
below, it could not be raised or moved upwards. This lady has suffered much from 
the displacement, irritation and fever; frequent calls to micturate, and difficult defe- 
cation, have injured her health and destroyed her comfort. She has scarcely any 
idea how the mischief happened, the only circumstance remembered being the oc- 
currence of uterine spasm from injections of cold water for monorrhagia. The 
attack was severe, and she has never been quite easy since. As yet the efforts at 
replacement have been unsuccessful. No practitioner could be in doubt about the 
existence or precise nature of the retroflexion, were two such cases as these to fall 
within his observation. 



HERNIA OF THE UNIMPREGNATED UTERUS. 

This most uncommon malady is ordinarily denominated hysterocele, 
and as a displacement, may occur either during the pregnant or unim- 
pregnated condition of the organ. The position, however, of the uterus 
in the centre of the pelvic cavity, with the bladder before and the rec- 
tum behind, and the broad ligaments stretched out on either side, would 
seem, were it not for the cases which follow, almost to forbid its taking 
place when the organ is in an empty state ; nor is it less difficult to 
imagine its occurrence during impregnation, except in the earliest 
months, and in a dilated state of the abdominal rings. There is not 
on record, I believe, a single case of hysterocele in a virgin subject. 
An example of herniary or extra-abdominal protrusion fell under my 
notice some years since, and as it must be exceedingly rare, I shall 
insert it here, and add two cases of undisputed hernia uteri. The 
treatment consists in the application of bandages and trusses as preven- 
tive measures, where the disease is only commencing ; and by their use 
to prevent a return when it has once been reduced. " In the event of 
strangulation taking place," says Dr. Davis, " there should not be a 
moment's hesitation as to the obligation of performing the operation 
required in that case without delay." 

In 1833, August 5th, I visited Mrs. D , at Woolwich, in consultation with 

Dr. Stewart of the Artillery and Mr. Butler, Senior, of Woolwich. The lady, a na- 
tive of Malta, had till within the last few years resided in that island, and shortly 
before coming to England had been dangerously ill from epidemic fever. As the re- 
sult of this attack, a large abscess had formed in the linea semilunaris of the left side, 
and a considerable portion of the muscular structure was destroyed by ulceration. 
The matter was evacuated by the lancet, exceeding a quart in quantity. In the 
course of a few weeks partial granulations were formed, and the wound was cica- 
trized ; but there was evident loss of substance about the part, and a depression 
existed in the adjacent muscle, of the size of a crown piece; satisfying Dr. Stewart, 
that in this spot there was only peritoneum and the common integument, the inter- 
vening tissue having disappeared. She conceived almost immediately, and came to 
England. At my visit she supposed herself more than seven months pregnant, and 
the question to be determined was, whether extra-uterine pregnancy existed 1 This 
was soon determined in the negative : it was a case of extra°-abdominal, not extra- 
uterine pregnancy : and the appearance of the patient was most singular. Through 
the aperture in the abdominal muscles, the uterus had gradually passed, soon after 
rising out of the pelvis ; and in proportion to its subsequent growth, the fundus 
had descended lower and lower, covered, not as in ordinary pregnancy, with the 
abdominal integuments entire ; but only invested with the peritoneum and skin ; 



DISPLACEMENTS OF THE UTERUS. 435 

so that at this period (probably a little beyond the seventh month), the gravid womb 
formed an immense ovoid tumour, the greater extremity being inferioHy, reaching 
nearly to the left knee, the tumour gradually diminishing in breadth as it approached 
the abdominal aperture. The os and cervix were, however, within, so that there 
was great stretching of the uterine walls in the erect posture, and there must also 
have been considerable curvature at this point. The movements of the child were 
distinct and strong. 

We agreed that she should maintain the recumbent posture till labour occurred, 
and then that she should be delivered on the right side ; the womb being supported, 
and its rectum into the abdominal cavity being aided by gentle manual pressure. 
Mr. Butler, who attended her confinement, told me, it required a good many hours 
of pain and gentle pressure to get the uterus replaced ; but he succeeded, the pre- 
sentation was natural, and both the labour and recovery were good. 

Cases 91 and 92. 

For the following cases T am indebted to Dr. Davis. Vide Principles of Obstetric 
Medicine, Vol I. p. 506. 

k One of the first recorded cases of hernia matrices in an unimpregnated subject, 
is that which we find reported by Professor Lallement in the Memoirs of Ihe Medi- 
cal Society of Emulation, torn. III. p. 323. The subject of the case was an old 
washerwoman, who had many children ; but without having experienced anything 
unusual in her labours. At about the age of 50, when her menses ceased, a swelling 
presented itself at the right groin, in consequence of a strong bodily effort. This 
tumour was of a pyriform shape, and of length equal to five fingers' breadth. From 
its being painful at first, it soon afterwards became insensible. The subject of the 
case, some time subsequently, availed herself of an asylum afforded her at l'Hospice 
de la Salpetriere, where she died at the age of 71. On dissecting her, Professor 
Lallement found, in a very think herniary sac, the whole of the uterus together 
with the Fallopian tube and ovary of the right side. The other ovary and its tube 
were seen to border the outside of the ring. The vagina was drawn violently up- 
wards, and put upon the stretch by the uterus, so as to cause pressure of the bladder 
against the pubis. The upper part of the vaginal tube had indeed been carried 
through the ring, together with the vaginal part of the uterus, which it embraced. 
M. Lallement. directed particular attention to this circumstance, as a feature in the 
case which should be considered as one of the most certain indications of an inguinal 
hernia of the uterus. M Murat in his article on Hernia of this organ, Diet. Scienc. 
Med., torn. xxxi. p. 227, quotes also the following case : — 

"Maria Michel Dubourg, of a remarkably lymphatic constitution, was the mother 
of eight children, whom she bore without any unusual difficulty. In about eight 
da\s after the birth of her last child, when she was 40 years of age, she resumed the 
duties of her laborious calling, viz., that of a washerwoman ; and soon after ob- 
served a small tumour presenting itself on the lower part of the groin. She suc- 
ceeded in effecting its reduction, but took no olher precaution. In about a year 
afterwards she was seized with paroxysms of abdominal pains, accompanied by 
nausea and sickness, which being from time to time repeated, she was induced to 
wear a bandage; which, however, she soon again neglected. The tumour increased 
in size, and eventually became irreducible. From the age of 74 to that of 82, the 
poor woman continued to be subject from time to time to attacks of nausea, pains of 
the bowels, and sometimes to vomitings. At length, on the 19th of December, 1815, 
some additional symptoms of strangulation presenting themselves, she was induced 
to seek admission into the Infirmary of the Salpetriere. The tumour was charac- 
terized by the following properties : It was situated in the right groin. It was of an 
enormous size, measuring five inches in length and four in breadth. Its form was 
that of a three-sided pyramid. Of these sides, one was directed forwards, another 
backwards, and was in contact with the right thigh, and a third inwards, towards the 
vulva, beyond which it descended some inches. It was larger in the middle than at 
its base, which was uppermost; its summit being inverted. Its direction was 
obliquely from the right to the left, and from above downwards. The integument had 
so much yielded, that it really formed a pendent bag between the thighs. The fin- 
ger, when applied above the tumour, could easily recognise the inguinal ring in its 



436 DISPLACEMENTS OF THE UTERUS. 

natural state ; and immediately below was felt the crural arch. The great volume 
of the hernia, and the very moderate intensity of the symptoms of strangulation 
which distinguished it, led to the belief that its contents were chiefly epiploic ; and 
that if it contained any internal structure, its usual and proper character must be 
greatly distinguished by its being included within an investment of omentum. The 
size of the tumour, the inconsiderable violence of its accompanying symptoms, the 
advanced age of the patient, and especially the bad state of the pulse, were all cir- 
cumstances which contra-indieated an operation ; and accordingly the treatment was 
limited to the exhibition of laxative tisans and emollient enemata. These means 
proved sufficient to relieve the symptoms of strangulation ; but the patient died soon 
after of adynamic fever. On examination of the body after death, the integument 
was found quite sound, and beneath it a considerable quantity of adipose substance. 
The herniary sack was with difficulty to be recognised. Deeply seated there was to 
be seen a considerable mass of lardaceous fatty substance. This, upon dividing it, 
appeared to consist of two layers ; one external, and the other internal. No portion 
of the intestine was implicated in the disease, and the visceral contents of the hernia, 
which were everywhere adherent to the adipose substance which surrounded them, 
were, the uterus, the ovaries, and the Fallopian tubes, a part of the vagina, two dis- 
tinct coils of epiploon, and finally two distinct cysts, or perhaps hydatids. The hernia 
was a crural one. The upper part of the vagina, greatly elongated, as indeed was 
the whole of it, formed a part of it. The bladder and the rectum were in their na- 
tural situation. Bulletin de la Faculte de Medecine de Paris, An. 1816, No. 1. 

"It seems possible that a hernia of the uterus might exist as a congenital mal- 
formation. The author is, however, not aware of the existence of a case in illustra- 
tion of this point, excepting that of the remarkable Humbert Jean Pierre, as reported 
by M. Maret in the second volume of the Memoirs of the Academy of Dijon, and 
quoted at length in a preceding article; see p. 66 of the present work." 






CHAPTER VII. 



DISEASES OF THE OVARIES. 



General Observations. — It is not within the scope of this work to enter 
into the anatomy and physiology of the ovaries and Fallopian tubes. I 
presume that knowledge so essential to a correct appreciation of their 
pathology, cannot have been neglected by any individual intending to 
engage in the cure or palliation of their numerous and complicated 
diseases. Of all the female genital organs, there are none so essential, 
none which exercise such influence as the ovaries; so that in reference 
to physiology, obstetric practice, and forensic medicine, they deserve 
the most careful study. Perhaps, too, there are no viscera whose 
organic changes can be more readily observed, as there are few 
museums, even of moderate extent, which are not rich in preparations 
showing the results of their formidable maladies. The structure of the 
ovaries is complicated, the vesicles of De Graaf being their most 
important part. 

These lie in the parenchyma or loose cellular tissue of the organ, 
with a thick, opaque capsule, the tunica propria, itself invested by a 
reflexion of the peritoneum. When it is remembered how intimately 
this complex organ is connected with the uterus and Fallopian tubes we 
need not be surprised at the variety and difficult diagnosis of its various 
affections. The chief function of the ovaries cannot be performed 
without the assistance of the Fallopian tubes; nor is it often that inflam- 
mation attacks either the uterus or the ovaries without their participation, 
not only in the attack itself, but in its more remote consequences. 

Ovarian are not so common as uterine diseases, probably because the 
ovaries, in the performance of their important functions, are not so much 
exposed to circumstances likely to induce deranged action, being 
entirely free from the irritation of morbid discharges, and far less 
exposed to external injury and the immediate and local effects of ex- 
cessive sexual intercourse. But, this partial immunity from disease is 
more characteristic of the early, than of the reproductive and more 
advanced period of life. It is true, that morbid lesions are uncommon, 
although not altogether unknown, before the age of puberty. After- 
wards, however, the ovaries are subject to excitement before and during 
menstruation ; the state of the Graafian vesicles, too, is liable to sudden 
change, not only as the natural result of conception, but from ungratified 
sexual feeling and acute or chronic inflammation;— the investing tunic 
must also be torn whenever impregnation occurs; and when to these 
conditions we add the consequences of menstruation, labour, and the 
puerperal state, we can have no hesitation in believing, that the ovaries 



438 DISEASES OF THE OVARIES. 

and Fallopian tubes must, for many years of female life, be common seats 
of disease. 

I shall first consider inflammation of the ovary, both acute and chronic; 
afterwards dropsy in its various forms ; and then add a brief description 
of the other organic and malignant affections which less frequently attack 
these parts. 

Inflammation. — Allusion has been already made to the injurious 
effects of uterine congestion, whether it occur in connexion with men- 
struation or from sexual excitement. The ovaries participate in these, 
and many of their slighter vascular changes, especially the small effu- 
sions of blood into the Graafian vesicles and into the structure of the 
ovary itself, may be traced to this cause. Inflammation of the ovaries 
is both acute and chronic, the former generally occurring in connexion 
with inflammation of the uterus, broad ligaments, or peritoneum, and 
therefore usually a puerperal affection ; the latter is commonly a conse- 
quence of the acute form, but it may, like the acute form, occasionally 
exist as an idiopathic and distinct affection. 

Although acute ovaritis is rarely found apart from inflammation of the 
uterus, occurring either in the pregnant or puerperal state, there can 
be no doubt of its occasional isolation.* " Inflammation of these 
organs," observes M. Portal, " has been known to exist independently 
of any similar condition of the uterus itself." He asserts, "that he had 
often met with patients of this class, who had experienced all the 
pathognomonic symptoms of inflammation of the uterus, but who, after 
the lapse of some time, and subsequently to their apparent recovery, 
became the subjects of fulness, and in fact of very great intumescence 
in one or both iliac regions, for which they took various remedies 
without advantage. On inspecting the bodies of such persons after 
death, he found the uterus perfectly healthy, whilst the ovary of one 
side, and in other cases of both sides, together with the ligament or 
ligaments, round and broad, of either or of both sides, presented the 
appearance of great engorgement." 

Probably in most instances the whole structure of the ovary is 
affected ; but it is possible that the inflammation may be confined to 
one vesicle, and may result in circumscribed abscess, or in some of 
those changes in its fluid contents, w T hich we so often see after death. 
In this way, the coats of the vesicle become thickened, inclosing con- 
cretions of various colour and consistence, which may be the com- 
mencement of those solid growths so often found in the parietes of 

* Some years since, in consultation with the late Dr. Cholmeley, of Guy's Hospital, 

I attended Mrs. , aet. 39, the mother of several children, for what we supposed 

to have been acute inflammation of the unimpregnated uterus. She recovered with 
great difficulty. Immediately afterwards, she began to suffer pain, and to enlarge in 
the left iliac region. Dr. Cholmeley was again called, and we feared that it might 
be commencing ovarian dropsy. She was advised to keep quiet, and not to take any- 
thing beyond mild aperient medicine She continued, however, to enlarge, and in 
the course of three weeks without any aggravation of the ovarian symptoms, she died 
from neglected pneumonia. On inspecting the body after death, we found the uterus 
entirely free from all appearances of inflammation ; but the left ovary was enlarged 
and highly vascular, and in one spot there was an evident cyst, containing healthy 
pus. The Fallopian tube was thickened and adherent by its fimbriated extremity to 
the surface of the ovary. 



DISEASES OF THE OVARIES. 439 

ovarian encysted dropsy. There can be no doubt that inflammation of 
greater or less intensity and isolation, either affecting the vesicles of De 
Graaf or by the formation of new and morbid cysts, lies at the founda- 
tion of those numerous ovarian diseases which slowly, but sometimes 
more rapidly, destroy the function and eventually disorganise the struc- 
ture of these organs. 

The causes are commonly puerperal. Certain types of epidemic child- 
bed fever, as the records of our various obstetric institutions prove, 
are characterized by the prevalence of this form of inflammation. It 
is not necessarily confined, however, to labour and its consequences, 
but may arise from cold, a blow or fall, and, according to Dr. Seymour, 
from the presence of some foreign bodies (as hair, teeth, &c), in the 
ovary itself. 

In one fatal case, an out-patient of Guy's, which I saw only a few 
hours before dissolution, the inflammation arose from sudden suppres- 
sion of the catamenia. The patient was seized, having sat in her wet 
clothes for some hours, with violent pain in the left iliac fossa. In four 
days she died ; and on inspection of the parts, the uterus was found to 
be large and soft, but without marked evidence of inflammation ; the 
left ovary had been intensely inflamed, pus had formed in its structure, 
and ihe whole organ was almost in a state of disorganization. 

Symptoms and Diagnosis.— The symptoms of acute ovaritis are not 
the same in the isolated and puerperal cases. In the latter, the more 
general form, the inflammatory affection of the ovary is only a part of 
the more extensive disease, and the local ovarian symptoms are masked 
and indistinct, the danger being very great. Where the ovary alone 
is affected, there will be less constitutional disturbance, and conse- 
quently less immediate danger, whatever may be the ultimate result; 
but there will be dull pain, not in the hypogastrium, but deeply seated 
in one, or sometimes both the iliac fossae, accompanied with sensations 
of weight and heat, always aggravated by the erect posture or by any 
sudden movement, and by defecation. I have indeed known syncope 
induced by the severe pain consequent on getting up in bed to relieve 
the bladder. At first there is not much fever ; but if the disease is not 
early checked, the pulse will become quick, the skin hot, and nausea 
and vomiting will occur. In some cases there is pain, not constant, but 
occurring in paroxysms, in the loins and along the course of the thigh 
and leg of the corresponding side, if only one ovary be affected, and 
dysuria and tenesmus are occasionally present. If the disease has been 
neglected in its early stages, the ovary may become so greatly enlarged 
by the formation of matter in its substance, that it may be* distinctly 
recognised by pressure in the iliac region. It is manifest, however, 
that this can only occur where its size is considerably increased ; in 
other conditions, the transverse septum of the pelvis formed by the 
expansion of the broad ligament, will preclude its ascent, and thus pre- 
vent such a recognition. Examination by the rectum, recommended 
by Lowenhardtt, will aid the diagnosis ; but even here the size of the 
ovary must have greatly increased, or the finger will with difficulty dis- 
tinguish it. Nor must it be forgotten by those who rarely make these 
examinations, that the uterus is more readily felt than the ovary, and 



440 DISEASES OF THE OVARIES. 

may easily be mistaken for it. Where, however, the pelvis is not very 
deep, and the finger long, the diseased viscus maybe touched lying by 
the side of the womb, — of course, where it is swollen, enlarged by puru- 
lent formations and tender on pressure, the diagnosis will be certain. 

It has been already mentioned, that the pain is not severe ; but if the 
disease spreads to the uterus or peritoneum, it becomes exceedingly 
acute, and the whole of the phenomena of inflammatory fever will 
occur. It is not improbable, after an attack of acute ovaritis, that the 
catamenial function may become deranged, and if chronic inflammation 
succeed, the foundation may be laid for permanent organic disease. 
Professor Carus of Dresden attributes nymphomania to ovaritis. The 
former disease is happily so uncommon, that extensive observations 
cannot be expected ; but so far as my experience goes, I am decidedly 
of opinion, that sexual feeling is diminished, not increased, by ovaritis. 
In two instances, I am perfectly convinced, that the result of the malady 
was entire aversion to intercourse, and it is now allowed, that nympho- 
mania more generally depends on the external organs, so far as physical 
causes are concerned. 

The course of the malady is distinctly seen in the note below.* 

* M Mrs. S , aet. 40, of middling stature, delicate figure, and florid complexion, 

mother of several children (the youngest of which is eight years of age\ having 
hitherto enjoyed good health, was attacked on March 12th, 1829, with pains in the 
abdomen, when the catamenial period was just over, in consequence, as she supposed, 
of catching cold ; these pains increased considerably the following day, and 'com- 
pelled her to keep in bed. She complained of a continued throbbing pain on the 
right side of the abdomen, in the ovarian region, and a violent desire to pass water, 
accompanied with much painful scalding; the urine red and clear. On closer ex- 
amination, the abdomen appeared nowhere enlarged or tender, except in the above- 
mentioned spot, which was somewhat swollen ; and pressure here increased the pain 
considerably. The vagina was hot, but not painful, neither was the rectum; but, 
upon examination with the finger through this passage, the ovary of the right side of 
the uterus was found swollen and painful. There was general constitutional suffer- 
ing; the patient was feverish, with thirst, flushed cheeks, suffused eyes, a white dry 
tongue, pain of head, pulse quick, but neither full nor hard. She was put on a strict 
antiphlogistic treatment, and recovered in the course of eight days. 

" On the 17th of April of the following year, an alarm of fire in the night was the 
cause of her catching another severe cold. She passed a sleepless night, had fre- 
quent rigours, with pain in the same side of the abdomen as in the former year, and 
suppression of the catamenia, which happened to be then present. The next morn- 
ing she complained of dull pain on the right side of the abdomen, in the same spot 
as formerly, much increased on pressure; but it appeared to be deeper-seated this 
time, and the abdomen was not so swollen. She experienced a constant forcing to 
evacuate the bowels without effect, but this time she had no difficulty in passing 
water. The catamenia had ceased entirely, and the vagina felt hot and dry. Intro- 
duction of the finger into the rectum produced pain. The ovary was evidently in a 
state of inflammation, but this time it was more swollen and painful. The constitu- 
tional symptoms were more marked during this attack : the skin was hot and dry, and 
she had much thirst. She complained that her head was confused; the pulse was 
126, not particularly hard ; the urine sparing and red. She was bled to ten ounces ; 
twelve leeches were applied to the abdomen, which was afterwards fomented with a 
narcotic application ; and she took a grain of calomel every two hours. 

**19&. Her general condition appeared somewhat improved, but the pain of the 
abdomen was not abated, and the impulse to strain (during which only a small 
quantity of mucus passed) was rather increased. The bowels had not been moved, 
although she had taken ten grains of calomel, and enemata had been instantly re- 



DISEASES OF THE OVARIES. 441 

Chronic ovaritis presents the same kind of symptoms, though less 
marked than those accompanying the acute form. Probably some of the 
most obscure cases occurring in medical practice belong to this class, 
especially where we cannot trace the symptoms to an acute attack. 
If considerable thickening or enlargement exist, or if there be fluc- 
tuation in the site of the ovary, the diagnosis may be tolerably certain; 
but in the more frequent examples, where a dull pain only is felt, with- 
out any perceptible increase of volume, the opinion must be a doubtful 
one. If both ovaries are chronically inflamed, or even where only one 
has been thus affected, disordered menstruation and sterility may ensue ; 
the latter evil being the result of the thickened state of the tunic of 
the ovary, and of the obliteration of the canal and of the fimbriated 
extremity of the Fallopian tube. 

Terminations. —Acute ovaritis may result in the chronic form ; and 
both may terminate in resolution, menstruation recurring; and if the 
patient have been recently confined, the lochia may re-appear. If 
death occur in this stage, the ovary scarcely presents any increase of 
size ; but it is red, the vesicles larger than natural, and numerous capil- 
laries traverse its surface. 

If the inflammation extend to the peritoneum, uterus, and broad liga- 
ments, although it is far more common for the ovaries to become in- 
flamed secondarily, the danger will be increased ; but if death takes 
place, the results of inflammation are not confined to increased vascu- 
larity, but there are effusions of lymph, false membranes, and organic 
changes in the ovary itself. 

Thickening and enlargement of the organ is another result.—" Such 
cases,'' says Dr. Seymour, " after the commencement of the disease, 
will often remain stationary and without any inconvenience for manv 
years." J 

There are examples of the ovary becoming soft and pulpy after an 
acute attack; and recovery canpot be expected here, more especially 

turned without effect. Twenty more leeches were applied to the painful spot, and, 
moSia £1 T P? wders ' sh e w as directed to take an oleaginous emulsion. 
jiWh. I he bowels acted twice during the night, and the irritable state of the 

rectum was somewhat diminished, but the pain in the abdomen was not much abated; 

the pulse continued quick, although neither full nor hard ; the heat of surface was 

moderate ; urine red and thick. Ten more leeches were applied. She was directed 
™ooi n ™ • u mercuriaI ointment every two hours, and take a warm bath. 

.. ,.*?*• Ahe night was passed more quietly than hitherto; the symptoms were 

bi?h a afil , ordereV 3016 remedieS Were again £ iven at lon S er interval^ and the warm 

"23d After a restless night, the local and general symptoms were found ao-ain 

aggravated. Twelve ounces of blood were taken, in spite of her apparent debility. 

w Tl g A U £ af u'- 8he falnted - ln order t0 modif y the action of the bowels, 

which had been much increased by the calomel, 1 added a little ext. opii to the emul- 
sion, and stopped the mercurial frictions. 

- This last bleeding produced a complete change. The next morning, every feel- 

ng of pain had nearly ceased ; the action of the mercury began to show itself upon 

the gums and salivary glands. Her recovery was somewhat retarded, from the 

nurses having continued the mercurial frictions the following night, contrary to 

order. 7 — British and Foreign Review, vol. ii., p. 528. 



442 DISEASES OF THE OVARIES. 

as such a form of the disease generally occurs as a complication of puer- 
peral peritonitis.* 

The formation of matter, and sometimes in very large quantity, is 
not an unfrequent termination of both forms of ovaritis. Andral quotes 
a case where the ovarium contained twenty pints of pus, and Portal 
mentions ovaria enlarged from the same cause, to the size of an infant's 
head. Suppuration will in most instances be indicated by rigours, 
quickness and softness of the pulse, a diminution of the general suffer- 
ing, and an increase of the local pain, heat, weight, and swelling. 

The abscess may empty its contents into the peritoneal cavity, either 
causing death in a few hours, or adhesion may take place between the 
surface of the ovary and some neighbouring part, and thus for a time 
the further escape of pus may be prevented. 

It is not uncommon for the matter to point at some spot in the iliac 
region, and there are many recorded cases where the abscess has either 
burst spontaneously or been opened by the lancet. f Occasionally, also, 

* The following ease occurred in Guy's, under Dr; Bright's care, in the autumn of 
1823: — "The patient was a young woman of the lowest and most unfortunate class 
of females. 

"She was greatly emaciated, had a very quick and feeble pulse, a shining red 
tongue, and constant watchfulness. She suffered from constant and irrepressible 
diarrhoea, and for many successive days vomited both food and medicine; the cata- 
menia were absent. The case made a considerable impression on my mind, from the 
extreme emaciation and coliquative diarrhoea, without any evident symptom of dis- 
ease of the lungs or intestinal canal. After having been in the hospital about two 
months, she suddenly complained of the most acute pain over the abdomen, and in a 
jew hours expired. 

"On opening the abdomen, death appeared to have been produced by the affusion 
of a large quantity of pus into the peritoneal cavity, which escaped from an abscess 
in the right ovarium, which abscess appeared to arise from suppuration in the sub- 
stance of the viscus, similar in every respect to phlegmonous abscess in any part of 
the body, and not connected with any cyst or change or addition of structure, the pro- 
duct of morbid growth." 

" Softening also takes place as the result of acute inflammation of these parts. 
A case recently occurred under my observation, where death, from inflammation of 
the womb, occurred about three days after delivery. The whole of the cellular mem- 
brane under the peritoneal covering of the uterus, and under that lining the pelvis, 
was in a state of diffuse suppuration, and the absorbent vessels loaded with pus could 
be traced nearly as high as the diaphragm. The ovaria were in a state of extreme 
softness, presenting the appearance of a vascular pulp, but no purulent matter was 
visible." — Seymour on Diseases of the Ovaria, p 38. 

f June 6/h, 1844, I was requested by Mr. Watt, of Deal, to visit a lady a few 
miles from his residence. The patient was young, and had been confined for the 
first time about three weeks previously. There was nothing unusual about the 
labour, the child was healthy, and there had been a fair secretion of milk. From 
the first, however, and before delivery, she had complained of pain about the uterine 
region ; but more especially, just above the pubis and in the right iliac fossa. The 
symptoms soon became more acute ; the pain intense and preventing sleep, and the 
pulse rose to 140. Micturition and emptying the bowels produced exquisite suf- 
fering; and on several occasions the catheter was used. It did not appear that there 
had ever been any threatening of general peritonitis, the disease seeming to be con- 
fined to the uterus and its appendages. I saw Mrs. B. for the first time early in the 
morning. She was emaciated, restless and irritable, pulse 120, and compressible ; 
skin soft and moist, indicating declining power; and she was anxious about her 
state. On the left side of the abdomen pressure was well borne, but on the right, 
just above the symphisis, she could scarcely allow even the slightest touch ; and in 



DISEASES OF THE OVARIES. 443 

the matter finds exit through the uterus, bladder, or rectum. Such 
cases I have seen, both in hospital and private practice. 

The ovary has also descended, when thus emptied, into the recto- 
vaginal septum ; nor have there been wanting instances where pus has 
passed through the Fallopian tubes into the uterine cavity, whence it 
has found its way through the vagina. Boivin and Duge's remark, that 
pus has sometimes been discovered in the ovarian veins and lympha- 
tics ; and gangrene, although exceedingly rare, and not discovered 
till alter death, is one of the terminations. 

Nor will it excite surprise, that the more malignant affections can be 
traced to the disorganising effects of acute or chronic inflammation. 
Melanosis may justly be attributed to exudation of blood into the in- 
flamed tissue, and to the morbid changes subsequently taking place 
Ovarian and hydatid cysts, scirrhous, fibrous, and encephaloid tumours, 
may be traced to inflammatory action and its results. 

Treatment.— Whatever may be the result, the treatment itself of ova- 
ritis is fortunately far easier than its occasional diagnosis. When 
ovaritis is only a complication of puerperal inflammation of the uterus 
and peritoneum, the same measures may be employed. If the laro- e 
bleedings and the free exhibition of mercury shall cure the more dan- 
gerous affection, it is nearly certain that the ovaritis will be cured also ; 
and if it occurs as an idiopathic affection, it must still be actively and 
antiphlogistically treated. Bleeding, both general and local, diapho- 
retics, sedatives, and counter-irritation, are indicated. Probably blood- 
letting to faintness, if the disease is seen in its first stage, will advan- 
tageously precede other remedies. Hot fomentations of common snn, 
the flannel being well peppered before its application, will act as an 
effectual counter-irritant. Nor is it Jess important to secure some hours' 
sleep during the night either by the soap and opium pill or by an opiate 
suppository. Drastic aperients are to be avoided, but the bowels must 
be well cleared by calomel and opium, followed either by castor oil, 
a mild cordial aperient, or by an unstimulating enema. 

the right iliac fossa there was enlargement, bur, no perceptible fluctuation. Here, 
also, the i fingers could hard'y be borne, and it had been throughout the seat of the 
pr.nc.pal pa.n. There had been rigours, and daily or rather" nightly fever The 
os and cervix were swollen and somewhat larger than natural, bufw.Ihout any dis- 

nprfJ/nf'tr 8 T® T^S secretion about l »* ™gina ^an is usual at that 

period of the puerperal month. Pressure high up the canal and towards the riaht 

that g ^f,T ^^ ^^ Wh f n XFP* m * fin ^ er into the r « ctu «i' " vvas evident 
that the ovary was enlarged. Under these circumstances, we had little doubt of 
there being pelvic abscess and almost as little that the right ovary wats local ty 
As mercury and the antiphlogistic plan, with leeches, had been fully tried ; and as 
her powers were much exhausted and her mind depressed, we defer" ined l0 lav 
Wide all medicine except the necessary mild aperients aud a hght infusion of bark 
with an opiate at night and generous diet. I heard subsequent of he pro .res 
Mr VValt vaned the treatment and diet as occasion required, and o h ? e 30 h of 
Jane he informed me, that a few days previously he had opened a large abscess m 
the right iliac region. For some little time afterwards she was depressed, and there. 
iLo aflZ ™? d,S|,0S r n t0 *»* Al ^ toe. however, of this writing, she was 
ZLZ2 ' the wound was discharg.ng healthy matter, and the tenderness of 

ee 1 h W I VaS faSt Subsldln g' the a PP«tite was improving, and she could 

sleep without the opiate. 



444 DISEASES OF THE OVARIES. 

Local bleeding is an invaluable auxiliary, and the leeches may be 
applied either to the groins, vulva, or anus, and where the affection is 
isolated, to the cervix uteri. 

If matter does form, we must watch its progress ; for it may point 
either in the iliac fossa itself or lower in the groin. If the pain be not 
acute, or the patient too much exhausted, we may permit the ab- 
scess to burst spontaneously ; but if from feeble powers, or the thick- 
ness and induration of the integuments, this may be a prolonged pro- 
cess, then we may open it either by the lancet or caustic. The former 
is the easier ; the latter, from its producing adhesions between the 
ovary and peritoneum, and thus preventing the escape of pus into the 
peritoneum or cellular tissue of the pelvis, is the safer method. If 
matter be discovered through the walls of the vagina, an opening may 
be made either with a small trocar or lancet. Doubtless, in cases so 
full of interest, every precaution will be observed, both as to the gene- 
ral treatment and the evacuation of the pus. It can scarcely be too 
strongly urged, that sexual intercourse be avoided for some time; at 
least till the health is restored, and the local ovarian irritation has sub- 
sided. The published cases prove, that in some instances there is a 
proneness to the repetition of the malady. 

Chronic ovaritis requires little modification of this treatment. The 
same active depletion will be unnecessary ; but in its stead local bleed- 
ings and stronger counter-irritation maybe employed. Iodine and mer- 
cury, especially in combination, are useful, particularly where enlarge- 
ment or thickening have occurred. Pains, lasting for many months, 
not acute, but dull and heavy, frequently exist in the region of the 
ovary. These, probably, are the consequence of chronic inflammation ; 
and I mention them, because they are too often regarded as neuralgic, 
and treated accordingly, painful menstruation and sterility, lasting for 
several years, being their results. I have lately had under my care a 
case of this kind, and I see many. In this instance there had been two 
attacks of acute ovaritis, both idiopathic. Since the last attack, now 
several years ago, the patient has always suffered from ovarian pain, 
aggravated at the monthly periods, and by excitement. Iron, mineral 
waters, riding on horseback, and walking exercise, have been tried ; 
but with no other effect than an increase of her sufferings. Three 
leeches over the most tender parts of the iliac fossa, once every four or 
live days, and occasional leeching of the cervix uteri, with warm alum 
hip-baths, and a course of hydriodate of potass and infusion of bark, 
with mild opiates, have entirely removed these harassing pains. This 
•plan was followed for eight or nine weeks, during which time she was 
hardly allowed to stir from the sofa. 



DROPSY OF THE OVARY. . 

It is undoubtedly true, that of all the forms of abdominal tumours, 
excepting, of course, the tumour of pregnancy, there are none so com- 
mon as those which originate in the uterine appendages, particularly in 
the ovaria. These tumours, notwithstanding differences in their pa- 



DISEASES OF THE OVARIES. 445 

thological nature and history, have, when containing fluid, been indis- 
criminately denominated ovarian dropsies. Let it be remembered, how- 
ever, that, unlike most other forms of dropsy, the fluid here is encysted, 
not diffused ; and that, unlike ascites, so often the consequence of vis- 
ceral disease, ovarian accumulation commences from derangement of 
the ovary itself, and frequently for a long period, especially if confined 
to one ovary, exerts scarcely any injurious influence on the constitution. 

It is common, in the classification of ovarian tumours containing 
fluid, to enumerate as distinct forms some which rarely ever attain- suf- 
ficient volume to rise out of the pelvis, and which are scarcely there- 
fore appreciable by touch. This may be pathologically correct, but 
they can only be regarded as subordinate varieties, seldom requiring 
medical aid, at least in comparison with encysted dropsy of the organ, 
with the ordinary history of which we have unhappily too many oppor- 
tunities of becoming acquainted. Of these less important tumours — 

The first are simple bags or cysts containing serum attached either 
to the surface of the ovary, the broad ligaments, or Fallopian tubes. 
They seem to be endowed with all the functions of the peritoneum, and 
to receive their blood-vessels from the point of their origin. These 
vesicular cysts are very common, sometimes congenital ;* and generally 
small and pediculated, although they may attain to the size of an orange, 
or perhaps even to a still greater bulk. We have in Guy's Museum 
two specimens of this simple cyst developed in the broad ligament, and 
decidedly within the natural fold of the peritoneum. 

In one preparation, although the tube passes round the cyst, it is not 
materially changed from its natural condition, nor does it communicate 
with the cyst. The ovary, too, on this side is healthy. In the second 
specimen, where the cyst is of larger size, and developed also in the 
broad ligament, the Fallopian tube is on the outside ; but there is no 
ovary ; so that it is not certain if the cyst may not have originated in 
disease of the ovary itself. 

The second variety comprises dilatation and dropsy of the Fallopian 
tube. We have several preparations of greatly dilated Fallopian tubes 
— a state probably not unfrequently resulting from inflammation of 
the mucous lining — and there are two or three specimens of serous cysts 
developed in their parietes, but not communicating with their interior.! 
It is well known that these canals are often filled with serous fluid, their 
closure at one or both extremities having been previously produced by 

* Guy's Museum, preparation 2251, uterus and its appendages from a child. The 
Fallopian tubes tortuous and' distended by scrofulous or cheesy matter. A small 
peritoneal cyst is attached, by a long slender peduncle, to one of the tubes near its 
fimbriated extremity. 

f Guy's Museum, preparation 2252, a uterus and its appendages, with adhesions 
binding down the Fallopian tubes: one of them closed at its extremity by its adhesion 
to the ovary, and partially dilated. 

Preparation 2253, uterus and Fallopian tubes ; one of the latter greatly distended ; 
it appears to be closed towards the uterus. The other, which is but little dilated, 
communicates, by a large opening, with the cavity of the uterus. 

Preparation 2254, a half of the uterus, with the corresponding Fallopian tube, 
which is obstructed at both extremities, and was greatly distended with a dirty-brown 
uriform fluid. 

29 



446 DISEASES OF THE OVARIES. 

inflammation. I have seen these pouches of considerable size, but 
never of such volume as to attain an elevation above the pubis. Dr. 
Seymour has given a plate of a preparation in the Museum of the Col- 
lege of Physicians, which would contain half a pint ; and De Haen re- 
lates a case in which the Fallopian tubes weighed seven pounds, and the 
cavity contained twenty-three pints of fluid; and, he says, in other in- 
stances the quantity has been still greater. It may be remarked, that 
one of the most common morbid appearances, presented after death, by 
these canals, is the preternatural adhesion of their fimbriated extremities 
to the ovaries; a result of irritation and inflammatory action, often pro- 
duced by excessive and licentious sexual intercourse. Sometimes, also, 
these tubes are distended by purulent and scrofulous deposits. 

A third form of ovarian dropsy, consisting of a single cyst, is attributed 
to morbid accumulation of fluid in one or more of the Graafian vesicles. 
Such are often met with in the dead body, where the history during life 
does not disclose any marked symptoms of disease. I have often seen 
the parietes of these cysts thick and fibrous ; and their serous lining in 
such a state of vascular excitement, as would justify the conclusion, if 
life had been continued, that they might have grown into large unilocu- 
lar cysted dropsy. This variety is certainly uncommon ; but I believe 
that large cysts of the kind, eventually engrossing the whole structure 
of the organ, do occasionally exist. Whether they arise from dilatation 
and degeneration of the vesicles is a controverted point, although it 
seems to me highly probable. 

We have not in Guy's Museum any preparation of ovarian cysts con- 
taining acephalocyst hydatids.* 

Having disposed of these less frequent varieties of ovarian tumour, 
we come to the most common form, generally demominated " Encysted 
Dropsy of the Ovary." This may be regarded as a specific disease, 
consisting in a peculiar change of structure, and sometimes, but certainly 
not invariably, assuming in its progress, almost every variety of ma- 
lignant action. At page 272, I have said, " from all which has yet 
been observed and settled as true, it may, I think, be assumed, that the 
most frequent primary locality of cancer is not in the blood, but in the 
molecular structure of organised tissues or parenchymata, and that the 
deposit of the morbid material is dependent on perverted nutrition or 
secretion." Dr. Bright, supported by the demonstrations of Dr. Hodgkin, 
" that in many malignant growths, there is a regular cellular arrange- 
ment," has endeavoured to prove, " that malignant disease originates 
more peculiarly in the cellular tissue of the body, first displacing, and 
then gradually involving and implicating the proper structure of the 
organ in which it is developed." Encysted dropsy of the ovary, he 
says, affords some marked examples and very striking modifications of 
this fact ; " illustrating the extensive growth and propagation of malig- 
nant disease in the loose cellular tissue of an organ, the more essential 

* In the Philosophical Transactions, No. 140, Sampson describes an ovarian tu- 
mour filled with hydatids, containing 112 pounds of fluid : and another case is men- 
tioned by Willi, where the tumour weighed above 100 pounds, and contained partly 
hydatids and partly gelatinous fluid. 



DISEASES OF THE OVARIES. 447 

parts of which seem to present, in their natural structure, a prototype 
of that involved system of cellular arrangement observable in malignant 
growths.' 1 These opinions are probably correct, and yet there are not 
a few examples of encysted ovarian dropsy, where, after many years' 
duration and frequent tappings, the disease still consists of a simple cyst, 
filled with a serous, or from inflammatory action, a muco-purulent fluid. 
Nevertheless, encysted ovarian tumour may coexist with true malig- 
nant disease of the ovary, or may become the seat of malignant de- 
posit ; and most pathologists know, if it has no tendency. to become 
a constitutional disease, it spreads to neighbouring parts, and by mere 
continuity of structure, seems to amalgamate them into one common 
diseased mass (vide Case). Whether this form of ovarian dropsy ori- 
ginates in the loose cellular tissue of the organ, or in the vesicles of 
De Graaf ; whether, in other words, new structures in the form of cysts 
have been created, is, and perhaps will remain, a disputed point. I 
have sometimes thought it quite impossible, that the very numerous 
larger and lesser cysts, cavities, and vesicular bodies, seen after death 
to have made up the bulk of an ovarian tumour, could have originally 
formed any portion of the normal structure; and " yet, when we look 
to a portion of loose cellular tissue which has been distended with air 
or filled with serum, we find no apparent want of cellular cavities, to 
bear out the possibility of a contrary supposition." 

The name multilocular cystic dropsy, often given to this disease, de- 
rives great propriety from the fact, that there is rarely only one cyst. 
Generally we have many in a state of progress, some not larger than a 
walnut or even less; others of the size of an orange or a turnip, and 
one probably of vast bulk, capable of containing ten, fifteen, twenty, or 
even thirty pints of fluid, thus giving to the tumour many of the proper- 
ties of a unilocular cyst. Sometimes the cysts are smooth on their inner 
surface, or they may be studded with small malignant tumours. Their 
thickness is occasionally not more than that of a bladder, while at other 
times (vide Cases), it may exceed several inches, and have become in 
some parts nearly solid. Their contents are exceedingly various; from 
simple serum to mucus and pus, not excluding gelatinous and melanotic 
fluids, and the more solid atheromatous, encephaloid substances. Bone, 
teeth, hair, and even calcareous substances have been found. Usually, 
however, they contain serum more or less viscid and gelatinous, and of 
a pale straw colour. Not unfrequently it is dark as cofFee-grounds, or 
like dissolved currant jelly, evidently from effused blood, and of offen- 
sive smell. In some instances it is too thick to pass through even a 
large trocar, and these are generally cases of multilocular cyst, with ir- 
regularly thickened parietes. Nor is it uncommon for the interior of 
the cyst to be studded with malignant knobby excrescences, likened by 
Burns to the cotyledons of the gravid uterus of the cow. Such growths, 
even were there a predisposition to the obliteration of the sac by the 
growing together of its sides, would prove an insuperable obstacle. 
Where there is only one cyst; or where there is one very large and 
other smaller cysts, the contained fluid is generally more serous; but 
this may not continue to be its character after repeated tappings. It is 
a curious fact, that the different cells of the same ovarian tumour are 



448 DISEASES OF THE OVARIES. 

filled with different fluids; thus one large compartment may contain 
limpid serum, another a jelly-like secretion, and a third a fluid differ- 
ent from either. In the denser secretions it is not very unusual to find 
fat, hair, and imperfectly organised teeth. As these substances have 
been discovered in virgins, where the hymen was entire, they can 
scarcely be attributed to conception, subsequently interrupted and ren- 
dered abortive. How far such development may have resulted from 
excited and disappointed sexual feeling, it would be difficult to deter- 
mine ; but the more probable explanation is, that such products are the 
consequence of the confusion of two separate ova at the time of im- 
pregnation; one having been inclosed in and partially developed by the 
more perfect being.* It may also be mentioned, that these substances 
have been found in parts of the system having no connexion with the 
organs of reproduction. Dr. Gordon of the London Hospital met with 
a tumour in the anterior mediastinum, containing a portion of the su- 
perior maxillary bone, some hair and teeth ; and Sir Benjamin Brodie 
found several well-formed teeth in the bladder. 

If there be great variety in the size of ovarian tumours, in the density 
of their external coverings, and in the nature of their contents ; there 
is scarcely less diversity in the number of the cells, and in the thick- 
ness of the septa which separate them. In most of these compound 
ovarian dropsies, the number of cysts is very considerable ; as the 
larger cells have series of smaller ones developed and in the course of 
growth on their internal surface, so that when the disease has attained 
great bulk, this creation of subordinate cysts is almost interminable. 
Sometimes these cysts are separated from each other by thin and trans- 
parent septa ; in which case, it is possible that the sudden evacuation 
of one cyst may lead to the rupture of the separating wall and the eva- 
cuation of the contents of a second. This will, however, but rarely 
happen; as the septa are often thick, sometimes even more than an 
inch; so that if there be many such separations, it is quite possible that 
the solid part of the growth shall exceed the fluid contents. The pa- 
rietes, originally composed of fibrous or fibro-cellular tissue, are liable 
to great changes in the progress of the malady, and not unfrequently 
themselves become the seat of various diseased deposits. The interior 
of the cysts presents, as already observed, various appearances; some- 
times it is smooth and glistening, like the free surface of the perito- 
neum ; but occasionally it may be seen more like a mucous surface, 
with adherent lymph and other results of local inflammation. Blood- 
vessels ramify freely on the inner surface of the primary and secondary 
cysts, furnishing an ample supply of blood, and satisfactorily explaining 
their occasional rapid advancement prior to tapping, and the rapid re- 
accumulation of the secreted fluid after paracentesis. The adhesions 

* Dr. Hodgkin, in his Catalogue of the Preparations in the Museum of Guy's 
Hospital, says, " It is not impossible that twin conception may take place in such a 
manner that the rudiments of one foetus may be enveloped in those of another." 
Not only is the idea supported by the analogy with some of the inferior order of ani- 
mals, but instances like that preserved by Dr. Highmore, in the Museum of the Col- 
lege of Surgeons, "where there is an imperfect foetus and part of the viscera sur- 
rounding it, taken from the abdomen of a lad about 16 years of age," would almost 
defy any other explanation. 



DISEASES OF THE OVARIES. 449 

of large cysts to the neighbouring viscera, and the thickness of their 
peduncles, are points of great interest in reference to extirpation. 

Dropsy of the ovary is not confined to married women, or to those 
who have borne or are still bearing children. Single women are, 
taking a given number, and comparing them with an equal number of 
married females, most liable to the disease ; nor does the affection, ac- 
cording to the opinion of many, prevail towards the decline of life. It 
is most frequently seen between the ages of 20 and 35 ; when the pa- 
tient is in the prime of her womanhood, the reproductive organs ac- 
tive, and if not healthily employed, their very activity becoming a 
cause of disease. Ovarian encysted dropsy seldom shows itself before 
20, although I have seen several examples much earlier; one in par- 
ticular, where the patient had not reached the 18th year, and where 
the ovarium must have contained many pints of fluid. The disease 
had been stationary for two years, having commenced at 14, contem- 
poraneously with menstruation ; and as her health was not at all injured, 
I was asked whether she might not be married. I discouraged her 
from the step ; but in a few months she became a wife, and has sub- 
sequently borne several children, without any aggravation of the malady. 
It is not common for both ovaries to be affected, although there are a 
good many such cases recorded. It more generally happens that one 
ovary alone is the seat of the disease, menstruation and the capability 
of conception being but slightly interfered with. It has been conjec- 
tured by some, that the left ovary is more frequently affected. In the 
cases I have seen, this preponderance has not existed. 

Symptoms. — A tumour in one of the inguinal regions is usually the 
first symptom recognised by the patient. It will be found to arise out 
of the pelvis, either on one or the other side, and may be firm and 
smooth, or lobular and uneven. It is seldom painful, but may not be 
altogether devoid of uneasiness ; and I have sometimes been surprised 
to ascertain, that a tumour of this kind should grow sufficiently to 
reach the pelvic, and even the umbilical region, and have lost all trace 
of a lateral origin, without having once seriously excited the patient's 
attention. The process of growth varies greatly : for a time it is slow, 
and may be scarcely noted even from year to year ; soon, however, from 
some unknown cause, sudden and rapid increase takes place ; so that 
in a few weeks or months the disease may become large enough to fill 
nearly the whole abdomen, presenting the appearance of a pregnancy 
far advanced. Even after this, it may become stationary, and patients 
often lull themselves into the belief, by measuring inaccurately and by 
making the best of their inconveniences, that further accumulation does 
not occur. But it is only necessary to watch these cases from week to 
week, and we are soon convinced, that the tumour becomes more tense, 
the fluctuation more distinct, and the breathing more embarrassed. In 
a little longer time, increased evidence of pressure is derived from ac- 
cumulation of serum in the cellular membrane of the lower extremities, 
in the enlarged and dark appearance of the superficial veins of the ab- 
domen, and in general distressing discomfort. Sometimes up to this 
period there is not any severe suffering, and in the earlier stages of the 
disease, there are no indications decidedly diagnostic. The sense of 



450 DISEASES OF THE OVARIES. 

weight, dragging, and irritation are common to so many uterine affec- 
tions, that they cannot be relied on. Not unfrequently, even at an 
early period of the enlargement, there is oedema, numbness and hemor- 
rhoids ; more rarely dysuria and diarrhoea alternating with constipation. 
Burns says, that pressure upon the rectum, by arresting the progress of 
the intestinal contents, sometimes gives rise to great distention of the 
bowels, and also to dilatation of the uterus. Dr. Lee details a case, 
where an ovarian cyst, having become firmly impacted between the 
bladder and rectum, produced all the symptoms of stricture ; and in 
another instance, the neck of the bladder was so pressed upon by an 
ovarian or uterine tumour in the pelvis, that it was impossible for the 
bladder to be emptied without the use of the catheter. In such exam- 
ples a tumour may be found between the vagina and rectum. Often 
medical aid is not sought till the evils here described have reached 
such a point, especially the embarrassment of respiration and the painful 
tension of the tumour, as to render tapping indispensably necessary. 

The surface of an ovarian tumour is often quite smooth, or it may be 
tuberose ; the walls may be thick and fluctuation indistinct ; or the parietes 
being thin and the abdominal integuments attenuated, fluctuation may 
be perfectly evident : it must, however, be remembered, that this sign 
is less manifest in small than in large ovarian tumours. The uterus is 
higher than natural, and the cervix is often elongated when the cyst is 
large and greatly elevated towards the epigastrium. Burns thus de- 
scribes the progress of the malady: — 

" In the course of the disease, the patient may have attacks of pain 
in the belly, with fever, indicating inflammation of part of the tumour, 
which may terminate in suppuration, and produce hectic fever ; or the 
attack may be more acute, causing vomiting, tenderness of the belly, 
and high fever, proving fatal in a short time ; or there may be severe 
pain, lasting for a shorter period, with or without temporary exhaustion, 
and these paroxysms may be frequently repeated ; but in many cases, 
these acute symptoms are absent, and little distress is felt until the 
tumour acquire a size so great, as to obstruct respiration, and cause a 
painful sense of distention. By this time the constitution becomes 
broken and dropsical effusions are produced. Then, the abdominal 
coverings are sometimes so tender, that they cannot bear pressure ; and 
the emaciated patient, worn out with restless nights, feverishness, and 
want of appetite, pain and dyspnoea, expires." — [Midwifery, p. 84.) 

Diagnosis. — The lateral situation of encysted dropsy, and its com- 
mencement in one of the iliac regions, is a point commonly dwelt on as 
important in its diagnosis. This circumstance does not always serve 
us ; as the tumour often advances early towards the mesian line, and 
meeting with little resistance in that direction, soon takes up a central 
position in the abdomen. Slow progress is in most cases a condition of 
ovarian tumours ; but we have seen already how suddenly they may 
advance. 

As the ovarian mass grows, it rises in the abdomen, and pushes the 
intestines upwards, laterally and behind ; thus establishing a distinction 
between extensive ovarian dropsy and ascites, by the dull sound elicited 
on percussion anteriorly, in the more prominent parts of the cyst. In 



DISEASES OF THE OVARIES. 451 

ascites, on the contrary, if the peritoneum be not diseased, the intestines 
usually float in the secreted fluid, and in the umbilical and epigastric 
regions where they lie ; a distinct resonance follows percussion. In 
ascites, the effused fluid always sinks to the inferior part of the abdo- 
minal cavity, and will gravitate towards the lowest point, if the patient 
be placed in different positions ; while in ovarian dropsy there will be 
comparatively slight change in the situation of the fluid. Nor must it 
be forgotten, that ovarian enlargement is circumscribed ; while ascitic 
accumulation is diffused, and has a more decided sense of fluctuation. 

Where the cyst is yet contained within the pelvic cavity, it will be 
necessary to examine carefully, both by the vagina and rectum. If the 
finger be introduced into the bowel, it is possible to feel the posterior part 
of the fundus uteri above the tumour ; and in this way, in a case I saw 
with Mr. Baily of Limehouse, enlargement of the second ovary was 
ascertained. 

From retroversion of the uterus, dropsy of the ovary may be distin- 
guished by its slow progress, by the absence of the symptoms marking 
the invasion and continuance of the former malady, as well as from 
examination by the vagina and rectum. 

It is not always easy to determine that pregnancy does not coexist. 
In most cases careful and repeated examination will establish a just 
diagnosis. It will often be difficult, especially where the ovarian 
growth is small, to determine its precise character, and to distinguish 
it from tumours growing from the cellular tissue of the pelvis, and lodged 
between the vagina and rectum. 

When encysted dropsy has risen into the abdominal cavity, it will 
have, in some instances, to be distinguished, not only from ascites, but 
from 'pregnancy, a distended bladder, and from malignant disease of the 
ovary. 

From pregnancy the distinction is often difficult and perplexing. At 
page 248, 1 have narrated a case, where the diagnosis was of this kind ; 
and in a lady lately under my care, the wife of a surgeon, it was not till 
the sounds of the foetal heart were distinctly and repeatedly heard, that we 
could feel satisfied of the existence of this state. But even the stetho- 
scope must not in every instance be relied on ; for the " placental souffle" 
may be accurately imitated by the pressure of an ovarian tumour on the 
iliacs, or, on any of the large abdominal vessels. Still an attentive col- 
lection of the signs which usually characterize pregnancy, even when 
complicated with tumour, will go far to narrow the ground for hesitation, 
and every day will tend, if it be pregnancy, to render the case more 
clear. 

A distended bladder can only by great carelessness be mistaken for 
ovarian dropsy: the catheter, which should always be used when there 
is the slightest doubt, will establish the diagnosis. 

From malignant disease of the ovary without effusion, it will generally 
be distinguished by its manner of growth, its slow progress, and accu- 
mulation of fluid ; but there are many cases of ovarian encysted dropsy, 
in which it is impossible, from the beginning to the end, to make any 
marked distinction between it and malignant disease ; and after death 
it is often quite impracticable, in the disorganization which has taken 



452 DISEASES OF THE OVARIES. 

place, amidst the cells, indurations, fungoid growths, and diseased 
secretions, to point out the tissue in which the cyst containing the 
principal fluid had been first developed. 

But perhaps the most difficult part of the diagnosis has reference to 
the dropsy itself. It may have been distinguished from other affections ; 
but we are anxious to know, whether in the case under notice, there be 
few or many cysts ; whether the fluid be extremely viscid or merely 
serous ; whether there be scirrhous growths or other decidedly malignant 
affections complicating the principal disease ; and, if extirpation be 
contemplated, whether there be a narrow or broad and solid peduncle : 
and whether there be few or serious adhesions, rendering the tumour 
almost immovable. Some of these questions may be answered with 
tolerable accuracy ; but the most important can, for manifest reasons, 
receive only an unsatisfactory, because most uncertain reply. 

The extent of the tumour may generally be ascertained by a careful 
examination of the abdomen by touch and percussion ; except in those 
cases where it is so large as entirely to fill the whole abdomen, leaving 
unoccupied only the hollow spaces of the diaphragm and loins, and the 
cavity of the pelvis. A careful observer will be struck by the different 
appearances presented merely to the eye ; sometimes inequalities on 
the surface mark the probable existence of several cysts ; while, in 
other examples, the tumour is of rounded form, being thus in some 
measure distinguished from the more ovoid shape of ascites and the 
pregnant uterus. 

Firm pressure over the abdomen imparts a sense of extensive fluctu- 
ation, and brings us acquainted with any inequalities or indurations 
which exist in the parietes of the cyst itself: and considerable tact is 
sometimes required to distinguish these from the liver, spleen, or kid- 
neys. I have often known experienced pathologists hesitate as to the 
nature of these enlargements in or about an ovarian tumour. 

The sense of fluctuation is not uniform throughout the whole cyst. 
Sometimes it is indistinct below, where there may be great tension ; 
and evident above, where the growth is less confined. In repeated 
examinations, it may be distinct in one part and only slightly per- 
ceptible in another ; proving, the probable existence of a large and 
several smaller cysts. I saw a case lately, where there was fluid in 
the abdominal cavity, and it covered, when the patient lay on her back, 
the anterior surface of the cyst, the solid, resisting feel of which at 
once became evident, when this layer of fluid was removed by careful 
manipulation. The advantages of percussion are great in marking the 
progress of the disease, and in detecting the situation of the different 
abdominal viscera, and it may also, by the knowledge it thus affords, 
prevent the introduction of a trocar at a thick and solid part of the cyst. 
Nor is it unimportant, prior to the operation of tapping, to examine the 
state of the integuments underneath the skin, not only to ascertain 
whether there be any indurated deposits ; but also whether there be 
extensive adhesions between the cyst and the adjacent peritoneum or 
viscera. If such exist, the tumour will be moved only with the integu- 
ments, and these latter can scarcely be rubbed freely over the promi- 
nent part of the growth or gathered up in the fingers. 



DISEASES OF THE OVARIES. 453 

Ovarian dropsy has been mistaken for ascites; but in addition to the 
circumstances already mentioned, it may be remarked, that whilst in the 
latter disease the secretion from the kidney is diminished, in ovarian 
dropsy it is hardly interfered with, till mechanical pressure is made on 
the kidney, by the large and perhaps almost entirely solid ovary. Nor 
is the general health, as in ascites, early affected, the animal functions 
being seldom disturbed till a late period. 

Organic diseases of the other viscera have been mistaken for ovarian 
dropsy. Enlargement of the liver increases downwards and towards 
the left side ; enlargement of the spleen grows laterally, beginning from 
the left and encroaching inferiorly towards the right ; while a thickened 
omentum exists from its commencement as a solid tumour, without even 
the semblance of fluctuation. Still it must be kept in view, that mis- 
takes, totally inexplicable on any supposition either of want of know- 
ledge or want of caution, have been committed by the most eminent 
practitioners. 

We must therefore be especially attentive not to be misled by accu- 
mulations of air or feculent matter in the intestines, which may, from 
their frequent recurrence, have imparted an almost permanent charac- 
ter to the enlargements they have produced. In no other way is it 
possible to explain the disappearance of tumours, thought to be ovarian 
by Lizars, till an incision has been made for their extirpation, when 
substances, the existence of which would have been most strongly 
affirmed a few minutes before, were no longer to be felt. 

Prognosis and Terminations. — The progress and termination of en- 
cysted ovarian dropsy, have become subjects of the deepest interest, 
owing to the efforts lately made to cure the disease by extirpation. 
Whether this be a desirable, or even a defensible operation, must 
mainly depend on the knowm course of the disease, when either left to 
itself or treated with a view to palliation only. If it could be proved, 
in the majority of cases, that the malady did not shorten life nor induce 
severe suffering, few more operations would be undertaken. But the 
examples of this kind are, it is to be feared, only exceptional ; and yet I 
cannot divest myself of the idea, if our records were accurately kept, 
that a more favourable view might be correctly taken of the palliative, 
or indeed of any treatment which did not involve the necessity for this 
hazardous extirpation. Certain it is, that many women have lived to 
old age, who were the subjects of the disease ; and although a less 
number comparatively survive many years after tapping has become 
necessary, yet a collection even of these would go far to prove, that 
paracentesis is not by any means so fatal in this respect as has been 
supposed. Sebatier examined the bodies of several women who had 
carried these encysted tumours during half a century, without alarming 
derangement of health ; and the memoirs of the French Academy of 
Surgeons prove, that it may last 58 years ; while Nauche, as a summary 
of his own views, says, " dropsy of the ovary, then, is not a very 
alarming disease, unless it be very ancient and very voluminous. ,: 
The cases of frequent tapping recorded by Martineau, Portal, and many 
other surgeons, amply attest the protracted duration of life in associa- 
tion even with this stage of the affection. Nor, in a calculation of this 
kind, must it be forgotten, that numerous women have become preg- 



454 DISEASES OF THE OVARIES. 

mint, and have been many times safely delivered, notwithstanding a 
dropsy of one of the ovaries. Such cases have fallen under my own 
observation, and I could add others also where the malady, although 
of considerable size, has existed many years without tapping, and with- 
out indeed any other than mere palliative treatment. 

These considerations are entitled to great weight when determining 
the propriety of extirpation, uncalled for by present and great evils ; or 
where the operation, from the enthusiastic views of its patrons, is ur- 
gently recommended as a preventive of mischiefs which they deem, but 
not always on good grounds, to be prospectively inevitable. To ope- 
rate where the patient strongly desires it, from a conviction that her 
sufferings and the frequent repetitions of paracentesis, will otherwise 
prove speedily fatal, may not involve any distressing responsibility, 
especially where the condition of the tumour leads to the supposition, 
that the case is pathologically a favourable one. But there are ex- 
amples selected for operation far different from this. Take, for instance, 
a case which occurred to me a few months ago. A lady travelled to 
town from a considerable distance, anxious to have extirpation per- 
formed. On inquiry, I found she was 62 years of age, had never been 
tapped, although ovarian dropsy had existed for more than half her life. 
There was scarcely any suffering beyond weight and pressure, although 
the tumour was of immense size and partly solid. In such a case, it 
would have been highly culpable to have operated ; and yet a surgeon, 
over-zealous about the removal of ovaries, had induced the firm belief 
that it ought to be done. I need scarcely add that the patient, after 
being made acquainted with the great danger of the operation, was 
perfectly satisfied to remain as she was. Nor will the practitioner be 
less perplexed and distressed by such a case as the following, which 
occurred within my observation not long since: — A young woman, 
under 22, had ovarian dropsy ; her countenance bespeaking excellent 
health, and her history confirming the impression. Without inter- 
ference, many years might have been added to her existence ; and as 
one of the fortunate incidents of life, it might have so happened, that 
the tumour should cease to grow. But unhappily she was convinced 
that extirpation was proper ; the operation was most ably performed, 
and in a few days she died. These certainly are not the cases in 
which removal ought to be practised. If the operation is to become 
established, of which I have the strongest doubt, it must be confined 
to examples of the malady where tapping has already been so often 
performed as to preclude from the experience of similar cases, any idea 
that it can ever be dispensed with ; and where, we are confident, that 
great suffering must lead to early death. Perhaps this may be regarded 
as too limited a view of the value of extirpation, but it is, I think, the 
correct one. In such cases, if the diagnosis excludes the belief that 
there are serious adhesions, or malignant and solid growths compli- 
cating the tumour, and if the patient strongly desires it, the operation 
is defensible. In all other examples it can only rest on the patient's 
own views of her future prospects, and on a calculation of chances. 
She might live many years and without much suffering ; but she may 
die in a few years after great suffering; she determines, therefore, 
being courageous, and probably strongly urged by her surgeon, to 



DISEASES OF THE OVARIES. 455 

run the risk of immediate death for the hope of immediate and radi- 
cal cure. Whether she has done wisely to submit to such a hazard, 
a successful operation can scarcely prove ; that she has happily secured 
her safety, through imminent peril, such an operation does prove. 
Lithotomy, operations for hernia, and for securing large arteries, rest on 
different grounds. That they are essential to the patient's life, is a full 
justification of their performance ; for in all, even if not dangerous at 
the moment, it is certainly known that life will soon be destroyed, 
either by fever, gangrene, or loss of blood. Such, it has been proved, 
has not been the case in many of the fatal operations lately performed 
for extirpation of ovarian encysted tumours. It does not appear that 
statistics more favourable even than we have any right to expect, will 
materially change the aspect of the circumstances under which this 
operation is to be performed. It must, probably, from the impossibility 
of determining the real character and adhesions of the growth, ever 
remain an eminently uncertain operation. The extirpation, we are 
assured by the operators themselves, in a fit case, is far from difficult — 
would that it were more so — for then it would not be so readily under- 
taken. If it required as much surgical knowledge and skill to make 
these large and brilliant abdominal incisions, as to tie the subclavian 
artery or to perform a trying operation of lithotomy, the lives of many 
women would have been already spared, and fewer would be sacrificed 
for the future. What would be thought of the feasibility of any other 
operation involving life in the most imminent hazard, if we discovered 
that out of 67 cases where it had been attempted, it was, /rom absolute 
error of diagnosis , incapable of completion in eighteen ; that of the re- 
maining 49 patients, where the extirpation was effected, sixteen died 
and two were not cured ; so that out of the whole number 67, the opera- 
tion failed in thirty-six and succeeded in thirty-one, less than one-half. 
Such results are distressing, especially when we hear no greater doubt 
expressed about the operation itself, but only higher confidence in its 
value, and greater laudation of the operators. We willingly concede 
presence of mind and ability to many of the extirpators of ovarian cysts ; 
but we are unable to discover (for the latter operations have been quite 
as unsuccessful from unfitness of the cases as the earlier ones) that any 
advance has been made in diagnosis. Nor, when the tumours them- 
selves are examined after death, when the malignancy of many of them 
is recognised, and their firm, almost indivisible adhesions, and their 
immovable masses of new and morbid substance are brought to view ; 
it is next to impossible to entertain any sanguine hope, that our means 
of diagnosis can ever be much improved. 

I have never known a case of absorption of the fluid of an ovarian 
dropsy ; but such are recorded. Denman and Hamilton are somewhat 
sanguine on the point. The former says, " that in several cases the 
disease had been removed without the use of any medicine, or any 
adequate evacuation, or his being able to discover how the fluid was 
carried off."* 

* In a case related by Denman, of enlarged ovary, a great quantity of glutinous 
matter was passed by stool for three successive days. The tumour lessened in pro- 
portion to the discharge, and ultimately disappeared entirely. 



456 DISEASES OF THE OVARIES. 

Dr. Hamilton confirms these views by stating, that after 16 years' 
trial, he has succeeded in a number of cases, in curing or retarding the 
disease, by firm compression of the abdomen, percussion, the warm 
bath, large and long-continued doses of the muriate of lime, in associa- 
tion with means for the improvement of the general health. This, it 
is to be feared, is too favourable a representation ; and all which can 
be granted is, that in some few examples the effused fluid does appear 
to have been absorbed, or at least to have disappeared. 

Adhesive inflammation sometimes takes place between the serous 
covering of the tumour, and some of the neighbouring viscera, as the 
colon, vagina, bladder, or small intestines ; and if ulceration occurs, a 
rare event, the fluid is evacuated and temporary relief obtained without 
tapping, and, according to Denman and Seymour, a perfect cure has 
been the occasional result. 

I have had a case under my care lately at Kensington where the sac 
from time to time opened externally, through the umbilicus ; thus, by a 
natural tapping, relieving all the symptoms. At length, however, in- 
flammation arose in and about the cyst, and death quickly followed. 
This spontaneous relief had existed for more than three years. 

Dr. Blundell saw a patient at Guy's, where the enlargement of the 
abdomen was occasional, and the woman got better repeatedly, after 
large spontaneous eruptions of water, by vomiting and purging. He 
had no doubt that the dropsy was ovarian, and in all probability the 
cyst occasionally opened into the intestines by ulceration or rupture, 
thus evacuating its contents. Many cases of this kind might be ad- 
duced ; but although the operation of tapping is dispensed with, the 
cyst neither becomes obliterated, nor does it cease to secrete. 

Occasionally the tumour is attacked by inflammation, and the patient 
dies either in a few days or soon after the occurrence of suppuration. 
This may happen independently of any measures employed for the cure 
of the malady, but most generally it occurs after tapping. 

Treatment. — Much cannot be expected from medicine in this formi- 
dable disease ; although remedies as powerful as iodine, mercury, and 
the strongest diuretics have been ably and perseveringly used. The 
.radical cure contemplates, by some means or other, the removal or com- 
plete obliteration by adhesion of the sides of the cyst. 

At a very early period, and while the tumour is still within the pelvic 
cavity, it has been alleged by some practitioners, that various medicinal 
agents might, if they do not produce absorption, at least restrain further 
progress ; but I have already remarked that Denman* and Hamilton's 

* " In the beginning of this dropsy, when the increasing ovarium is first percepti- 
ble through the integuments of the abdomen, and sometimes in its progress, there is 
often so much pain, as to require repeated local bleeding by scarification or leeches, 
blisters, fomentations, laxative medicines and opiates, to appease it. I have also en- 
deavoured to prevent or remove the first enlargement by a course of medicines, the 
principal of which was the ung. hydrarg. rubbed upon the part, or calomel given for 
a considerable time in small quantities, with an infusion of burnt sponge ; or the 
ferrum tartrizatum or ammoniacale ; trying, occasionally, what advantage was to be 
obtained from blisters, from a plaster composed of gum. ammoniacnm dissolved in 
the acetum scillse; or, lastly, from electricity. From all or some of these means, I 



DISEASES OF THE OVARIES. 457 

opinions on the subject, have not been confirmed by subsequent expe- 
rience. 1 have sometimes found in the early stage of the disease, that 
local bleedings by leeches, followed by repeated blisters, kept on only 
for a few hours, and succeeded by linseed poultices for several days, 
have not only retarded further growth, but have even diminished the 
absolute bulk of some incipient ovarian tumours ; and I wish especially 
to observe, where this plan is intended to be beneficially followed, that 
the recumbent posture, avoidance of sexual excitement and great phy- 
sical fatigue, are indispensable conditions. Drastric purgatives, as they 
do not produce any effect on the contents of ovarian cysts, ought to be 
sparingly exhibited. Perhaps they should be limited to those cases 
where ascites coexists with the ovarian effusion. Mercury and iodine 
may be given up as remedies possessing any absorbent power ; they are 
therefore to be used only with the view T of remedying hepatic and 
glandular derangement, and of improving the general health. Either 
of these powerful agents, when given to excess, may break down the 
constitution and hasten the progress of the disease. The muriate of 
lime, so strongly recommended by Professor Hamilton, I have seen 
very largely tried, but without any marked benefit. 

There are effects consequent on ovarian growths, while yet in the 
pelvic cavity, and of small size, which claim attention. Pressure on 
the bladder and rectum occur, requiring the catheter, enemata, and 
sometimes an alteration of the position of the tumour itself, by raising 
it higher, and if possible above the pelvic brim. It may, however, 
happen, that the growth has already contracted adhesions with surround- 
ing parts, in which case protracted or powerful attempts at elevation 
may induce inflammation. Cramps and numbness may be relieved by 
friction with stimulating liniments and the horse-hair glove. 

Pressure by elastic belts or bandages is of old date, but it has pro- 
bably done more harm than good. In uterine fibrous tumours, it has 
often excited increased growth, by the discomfort and pain it has pro- 
duced ; and there is every reason to suppose, if carried to any undue 
extent, it would produce the same effect in ovarian cysts. 

Dr. Hamilton used a knobbed instrument for percussing these tu- 
mours in the intervals of the pressure : but even in Edinburgh, the 
practice is entirely abandoned. In the chapter on the "Induction of 
Premature Labour," a detail is given of the methods to be pursued 
when ovarian tumours complicate pregnancy and labour. 

When the dropsical cyst has become so large and tense as to impede 

have frequently had occasion to believe some present advantage was obtained, or 
mischief prevented; but when the disease has made a certain progress, no method 
of treatment has hitherto been discovered sufficiently efficacious to°remove it or pre- 
vent its increase." — Denman's Midwifery, p. 81. 

" When they (diuretics) produce any effect, it is chiefly that of removing dropsi- 
cal affection combined with this disease ; and in this respect they are most^powerful 
immediately after paracentesis. With regard to their power, or the power of any 
other medicine, of diminishing the size of the ovarium, my opinion is, that they have 
no more influence on it, than they have over a melicerons tumour on the shoulder, 
or over the disease when it occurs in the testicle, or over the configuration of the 
patient's nose." — Eurns's Midwifery, p. 141. 



458 DISEASES OF THE OVARIES. 

the functions of life, or to endanger its own rupture, tapping is our only 
resource ; we evacuate the fluid by making an incision through the in- 
teguments, and draw it off by a canula. This is generally, but not in- 
variably, a simple operation, and it is undoubtedly one of the safest of 
all the expedients for giving temporary relief. It does, however, ge- 
nerally happen, when the fluid has once been evacuated in this way, it 
rapidly re- accumulates, and it is often a matter of surprise that the ope- 
ration should so quickly require to be repeated, and that in the aggre- 
gate so large a quantity should have been secreted.* 

Frequent repetition, however, must be expected where the tumour 
is growing rapidly. The secreting or exhaling surface, especially if the 
dropsy consist of only two or three large cysts, becomes more extensive 
in proportion to the increase; and the arteries of the lining membrane, 
pressure having been taken offby the withdrawal of the fluid, will secrete 
more rapidly and largely. We cannot wonder, therefore, at the anxiety 
of practitioners to delay the first operation as long as possible, although 
it be the safest of our palliative resources. If the fluctuation is very 
indistinct, it may be presumed, that the tumour is divided into many 
cells, or that the secretion is remarkably viscid. But even here para- 
centesis should be practised ; as, although the relief be but partial, it 
may be sufficient to save the patient from the risk of suffocation, and 
to permit the kidneys and uterus, if they have been interrupted in their 
functions, again to perform them. 

When paracentesis has been determined on, and before its perform- 
ance, it ought to be ascertained that there is no pregnancy, and that 
the fluctuation does not arise from a distended bladder. Nor ought 
we to omit this examination when the tapping is repeated ; for the vis- 
cera may have altered their position relative to the diseased ovary, 
rendering necessary a change of place for the introduction of the trocar. 
It must not be forgotten, that for want of this caution, the abdominal 
and pelvic organs have been mortally wounded ; and no practitioner 
ought to be ignorant of the fact, that both the pregnant uterus and the 

* Dr. Mead relates, that Lady Page was tapped 67 times in five years (oftener 
than once a month), 240 gallons of fluid having heen abstracted. Morand drew off 
427 pints in ten months; "and Martineau 429 pints within a year, and from the same 
patient 6631 pints by 60 operations, within five years. He took away 54 quarts at 
one operation. Portal tapped a lady 28 times; and in a case related by Ford, there 
were no less than 49 tappings and 2649 pints withdrawn. Dr. Ramsbotham, senior, 
had a patient, who was either tapped by a surgeon, or performed the operation for 
herself, in the prominence at the navel, by means of a glover's needle, 129 times in 
eight years. Whenever she became distressed in breathing, and the navel protruded 
more than usual, she used to make four or five punctures with the glover's needle, 
and allow all the fluid that would to ooze away. It was a matter of surprise to all 
who were present at the examination of her body after death, that she never se- 
riously injured herself; for we found an old umbilical hernia, of very considerable 
size, bound down to the prominent portion of the umbilicus by strong adhesions. It 
had apparently escaped being wounded by its position behind the ovarian protrusion, 
whenever the collection of water was great, although it actually, by its size, added 
not a little to the bulk of the external tumour. " This had taught me" (says Dr. 
Francis Ramsbotham), " never to plunge a trocar into the swelling at the umbilicus, 
although the prominence of the tumour there, and the thinness of the structure, 
might otherwise tempt me to select that spot." 



DISEASES OF THE OVARIES. 459 

distended bladder hare been punctured, and with fatal consequences 
from having been ignorantly mistaken for a dropsical ovarian cyst 
Ihe patient ought also to be informed, that the operation may fail, for 
although in ascites the whole of the water is generally evacuated in 
ovarian encysted dropsy, owing to the extreme viscidity of the fluid or 
abTracted g C ° ntamed in se P arate cells > onl y a small quantity may be 

We should select the most prominent part of the cyst for puncture, 
it there be no solid deposit ; but we must avoid the navel. A We 
trocar is better than a small one, as the fluid may not be serous, and 
the instrument should be cautiously, yet boldly carried through the in- 
teguments. I have seen a timid surgeon foiled from not passing the 
instrument sufficiently deep, forgetting that the abdominal coverings 
may be very thick, and that the sac itself may be covered with fat or 
be very dense. The epigastric artery should be avoided; but even 
where this vessel is not wounded, some of the large blood-vessels 
ramifying on the surface of the tumour may be opened and an alarming 
hemorrhage may ensue. B 

These difficulties evaded, the fluid is to be slowly drawn off, and if 
there be syncope or an approach to it, the further abstraction may be 
stopped for a few minutes by plugging the canula with the tip of the 
linger or a small piece of tow, and by tightening the abdominal bandage 
previously placed round the belly. The extremity of the canula must 
not escape from the cyst, as the sac is being emptied ; for inflammation 
might follow the effusion of the fluid into the peritonea] cavity. 

Monro, Ledran, and some other authors, mention cases cured by 
paracentesis; and, to speak with caution, I have known several where 
after one or two tappings, an interval of six or seven years has occurred! 
without further evacuations being even then required. Such examples * 
may fairly so tar be regarded as cures. The evil consequences of pa- 
racentesis consist, in the fatal sinking which sometimes, although very 
rarely, immediately succeeds it ; in the rapid re-filling, an event hastened 
perhaps by the operation taking off pressure from the secerning capil- 
laries of the interior of the cysts ; in the occurrence of inflammation 
either m the sac itself, or in the peritoneal cavity. To these unfortunate 
results must be added, the want of success arising from extreme viscidity 
of the fluid, the existence of numerous and entirely separate cells, and 
Irom the complication of scirrhus or even of more malignant growths. 
Ihe wound of the trocar, in these latter conditions, may, by inducing 
.inflammation, accelerate the patient's dissolution. 

After the operation, absolute quiet in the recumbent posture should 
be insisted on ; and it has been recommended in a few days when ex- 
citement is subsiding, to exhibit diuretics and apply blisters 'to prevent 
re-accumulation. These means, however, have only very partially 
succeeded. / J J r - J 

Injection and Incision.— These are measures less formidable in some 
respects than extirpation ; but their consequences are sufficiently disas- 
trous to prevent their further use. It was supposed, from the success 
ol astringent and irritating injections in hydrocele, that happily a simi- 
lar good result might ensue from their use in ovarian dropsy. But it 



460 DISEASES OF THE OVARIES. 

was forgotten, that the surface is much larger, that the cyst itself is not 
only in the neighbourhood of the peritoneum, but that it is covered 
externally by a reflexion of this membrane. Hence the degree of in- 
flammation was so uncontrollable, that this measure may be regarded 
as entirely abandoned. One case I have appended, where I had an 
opportunity of watching the practice. 

Incision. — In some cases an -attempt has been made to procure ob- 
literation of the sac by incisions, setons, and by leaving the canula or 
sponge tents in the wound. These have now become merely matters 
of history ; for scarcely in our medical societies would more than an 
expression of surprise be elicited, either if a cure was obtained, or a 
fatal result evaded, after the employment of such means.* 

* Le Dran has given two examples (2d vol. of the Memoirs de l'Academie de 
Chirurgie) of incision. In one, after a free inci-ion into the cyst, the fluid was 
evacuated, suppuration established and a cure effected, although a fistulous orifice 
remained. In 'the second, a canula was introduced after the incision, and here there 
was febrile excitement, vomiting and delirium. The patient however escaped, and 
there was no further gathering of fluid, but as in the former instance, there was a 
fistulous opening for more than two years. 

In Laporte's case, to be found in the same volume, the contents of the sae being 
too solid to pass through the canula, an incision of five inches' length was made, the 
gelatinous contents were evacuated and the wound closed, Vomiting and fever came 
on, and in thirteen days the patient died. 

In Osiander's patient, the incision remained fistulous for a year, death eventually 
ensuing from peritonitis. 

Mr. Key says, the " issue (from leaving a piece of bougie in the wonnd made by 
the trocar) has not been such as to lead him to expect much from the plan." His 
were all cases occurring in Guy's Hospital ; in one the fluid was serous, in a second 
mucilaginous, and in the last like coffee-grounds. In all considerable distress was 
produced, consequent on the inflammation which supervened. In the first the fluid 
re-collected ; but the process established the sac seemed to retard its formation, 
for tapping was not required again for six months. The second patient was also 
tapped again, and died a year after the bougie had been introduced, whether in con- 
sequence°of the operation is not stated; and the third patient sank under the in- 
fluence of an abscess, which formed four days after the operation, and burst exter- 
nally at the opening made by the trocar. 

Denman notices the particulars of a case, where death occurred the sixth day after 
injecting the cyst. Mr. Ramsden made use of injections in two instances, and both 
died in consequence; Hamilton says, he once injected an ovarian sac with port wine 
and water, and the patient died in six weeks of chronic inflammation. 

Rigollet of Lyons relates the following example :— The patient was 23 years of 
age, and the tumour first appeared after labour. The second time it was punctured, 
a decoction of plantain and red rose leaves, with the addition of a little wine, was 
injected. While the fluid remained in the cavity, it occasioned acute suffering, and 
after its evacuation, M. Rigollet kneaded the cysts with his fingers, <« in order to de- 
termine its inflammation." Intense pain, vomiting, and swelling of the abdomen 
quickly ensued, and energetic antiphlogistic remedies were required to repress the 
inflammatory symptoms. In a month the cure was considered complete ; but there 
always remained in the abdomen a small, oblong, indolent tumour, doubtless the 
original cyst, whose parietes had become adherent together internally, and perhaps 
also to the peritoneum, on the inner surface of the abdominal muscles. 

For these notes of cases, 1 am indebted to the very able lectures of Dr. Francis 
Ramsbotham, from whom I take also the following extraordinary history :— - 

The most remarkable case, perhaps, on record, in which the practice of cutting 
into the cyst was adopted, is detailed in the thirty-third volume of the Philosophical 
Transactions, by Dr. Houstoun ; it occurred more than a hundred years ago, and 
proves the extent of injury which the abdominal structures will sometimes bear with 



DISEASES OF THE OVARIES. 461 

Extirpation.— After the opinions expressed when treating of the 
prognosis and termination of ovarian dropsy, I shall here content my- 
self with furnishing an account of the different operations which have 
been performed, appending Dr. Churchill's tabulated record of the cases 
themselves. 

Two modes of operation have been practised for the extirpation of 
ovarian tumours, one by an incision of small extent through the ab- 
dominal parietes, the other by a free and extensive section from the 
pubis to the epigastrium. In the former or minor operation, the bulk 
of the disease, where the contents are fluid, must be first reduced by- 
tapping ; the sac is then to be drawn out, its peduncle tied, and after- 
wards divided. The major operation contemplates the extraction of 
the tumour entire ; and it must be evident, that this method will enable 
the operator to deal with adhesions and peduncles, which would pre- 
sent great difficulties by the lesser incision. Still it is proved, that the 
proportion of deaths is greater in the larger than in the lesser operation. 
Out of 60 cases (vide Dr. Churchill's tables), the lesser incision was 
practised 22 times, and 16 patients recovered ; while out of 37 cases, 
where the larger operation was resorted to, only 22 patients recovered. 
Whether such results will be obtained in future, it is impossible to de- 
termine ; but I cannot see the necessity for always resorting to the large 
incision. In many of the cases where the long section was practised, 
there were no adhesions. In such, the sac might have been drawn out 
after tapping, a double ligature applied, and the uterine portion being 
left in the abdomen, the wound might at once have been closed. If, 
from the presence of solid matter, or the existence of many cysts, a 
small quantity only of fluid could be withdrawn, the incision might be 
enlarged, and the operation proceeded with as in the larger section,. 

impunity. The patient was 58 years old : and I shall quote to you his own words, 
because the mode of proceeding I deem to be without parallel. 1 certainly trust it 
will remain without imitation. 

1 The operation of puncturing the abdomen being proposed, the woman consented. 
Accordingly, with an imposthume lancet I laid open about an inch ; but finding no- 
thing issue, 1 enlarged it to two inches, and even then nothing came forth but a little 
thin yellowish serum; so I ventured to lay open about two inches more. I was not 
a little startled, after so large an aperture, to find only a glutinous substance bung up 
this orifice. The difficulty was, however, to remove it. I tried my probe, and endea- 
voured with my fingers, but all was in vain ; it was so slippery that it eluded every 
touch, and the strongest hold I could take. 

" I wanted in this place almost everything necessary, but bethought me of a very 
odd instrument, yet as good as the best in its consequences, because it answered the 
end proposed. I took a strong fir splinter, such as the poor in that country use to 
burn instead of candles. 1 wrapped about the end of this splinter some loose linS, 
and thrust it into the wound ; and by turning and winding it I drew out about two 
yards in length of a substance thicker than jelly, or rather like glue fresh made, and 
hung out to dry ; its breadth was above ten inches. This was followed by nine- full 
quarts of such matter as is met with in steatomatous and atheromatous tumou?s, with 
several hydatids of various sizes, containing a yellowish serum, the least of them 
larger than an orange, with several large pieces of membranes, which seemed to be 
parts of the distended ovary. I then squeezed out all I could, and stitched up the 
wound in three places." 

The patient recovered, and lived fourteen years afterwards without any return of 
the disease, — a fortunate termination to a very rough practice. 



462 DISEASES OF THE OVARIES. 

Mr. Walne's reasons for preferring the long section are these : " that it 
does not appear that a less extent of wound diminishes the danger of 
the operation in any material degree, if at all ; and that the compli- 
cations which occasionally present without being foreseen, and which, 
indeed, do not admit of being foreseen in every instance, can be better 
appreciated, and more suitably dealt with by the surgeon, through a 
free opening than through a small one. For example, the effusion of 
blood or the escape of fluid from the cyst into the peritoneum, either of 
which is a most dangerous complication of the difficulties inseparable 
from any method of operating, can with no certainty be avoided in the 
minor, but may assuredly be remedied if they should occur in the major 
operation. Adhesions, too, can be divided, the parts can be cleansed, 
and arteries tied with facility, if necessary, and the operator's mind 
freed from doubt as to the state of the internal parts, before he carefully 
closes the wound. These are circumstances which the experienced 
operator can appreciate, and if he should not be blinded by an undue 
apprehension of peritoneal inflammation, he will be sure to estimate 
highly such palpable advantages."* 

I am indebted to Mr. Jeafferson for a description of his method of 
operating ; and the following account is extracted from the Trans, of 
the Prov. Med. and Surg. Assoc, vol. v. p. 240 : — 

" Mr. J. had attended Mrs. B in her labour in Nov. 1833, and 

then discovered a tumour in the pelvis, which he succeeded in pushing 
above the brim of the pelvis, so as not to impede delivery. She was 
delivered of another child on the 4th of March, 1836, without any dif- 
ficulty, but after this the abdominal tumour increased so rapidly, that 
extirpation was determined on. 

" Accordingly, on the 8th, in the presence of my friend Mr. King, 
I made an incision of between 10 and 12 lines in the course of the linea 
alba, midway between the navel and the pubes, and having thus care- 
fully exposed the sac, I evacuated by the trocar about twelve pints of 
clear serum. During the flow of the serum, a portion of the sac was 
secured in the grip of a forceps, to prevent its receding ; and I after- 
wards gradually extracted the sac entire from the cavity of the abdo- 
men, together with another sac containing two ounces of fluid, and in- 
deed the entire ovary, having only to cut through a slight reflexion of 
the peritoneum, and the ovarian ligament, which, with the exception of 
a small portion of the fimbriated extremity of the Fallopian tube, are the 
only natural attachments of the ovary to the uterus. But as this part 
was the medium of vascular supply to the sac, and the vessels on the 
surface of the sac were unusually large, we thought it right to include it 
in a ligature previous to returning it into the cavity of the abdomen: 
the ends of the ligature were cut off' close to the knot. A very small 
portion of omentum protruded with the sac, but was very easily re- 
turned ; the external wound was closed with two sutures, adhesive 

* I acknowledge most willingly the talent and extreme care displayed by Mr. 
VValne in his operations, and especially in the after-treatment of his cases ; but I 
cannot, without considerable limitation, concur in the reasons for his preference of 
the larger over the smaller and safer section. 



DISEASES OF THE OVARIES. 463 

plaster, and a compress of lint ; and by Mr. King's advice I gave im- 
mediately a pill containing two grains of powdered opium, and a 
draught with a drachm of tincture of foxglove, keeping a napkin wrung 
out of the coldest spring water constantly applied over the whole abdo- 
men. In the night I gave doses of calomel and extract of henbane, and 
followed this by giving, every four hours, a solution of sulphate of mag- 
nesia in saline mixture." 

Two days after the operation, the patient was attacked by vomiting, 
sinking, and pain in the thigh, but under Mr. Jeafferson's judicious 
treatment, she soon rallied. . 

The sutures were removed 48 hours after the operation, when the 
wound was healed, except where the sutures had produced slight ul- 
ceration ; the plaster and compress were re-applied, and saline mixture 
with one drop of hydrocyanic acid was given every four hours." The 
woman, after this, did well, and has resumed her usual occupations. 
There was not, at any period, the slightest interruption to the secre- 
tion of milk, and only a little shooting pain occasionally where the 
ligature was applied. 

' Mr. King, of Saxmundham, has repeated this operation on a lady, 
when the ovarian sac was much more distended, and having evacuated 
271 pi nts of fluid, he extracted it entire, together with a tubercular tu- 
mour the size of a turkey's-egg. This lady has recovered without an 
unpleasant symptom." 

No doubt less hazard of peritoneal inflammation must attend su^h an 
operation, than where the abdominal cavity is laid open from the pubis 
to the ensiform cartilage ; and it will probably be also conceded, as al- 
ready observed, that in many instances, by a moderate extension of this 
incision, adhesions and peduncles capable of safe division may bebrought 
sufficiently within the scope of the knife and ligature. If the operation 
continues to be practised, these points will be fully elucidated, and the 
relative merits of the two kinds of extirpation will be fairly adjusted. 

[I take the following from some observations of Benj. Phillips, 
F.R.S., published in the London Lancet for July, 1844.— Am. Ed.] 

" Extirpation of ovarian cyst has been practised, as appears from the 
tabular arrangement of the cases, at least 69 times. In 50 cases, the 
tumour was extracted ; in 14 cases, adhesions or other circumstances 
prevented its removal ; in 5 instances no tumour was found. 

' Of the cases in which the operation was completed, the tumour being 
extracted, 30 terminated favourably, the patient recovered ; in 20, the 
termination was unfavourable, the patient died. Of the 5 cases in 
which no tumour was discovered, all recovered. Of the 14 cases in 
which adhesion or other circumstances prevented the extraction of the 
tumour, 8 recovered, 6 died. The proper way, therefore, according to 
the author, of looking at this plan of treatment, is to observe the num- 
ber of cases submitted to operation, and the number of recoveries after 
the removal of the tumour. He conceived this to be the fair way, be- 
cause what has happened already may happen again. Adhesions may 
be too strong and extensive to make removal prudent ; the tumour may 
be other than ovarian ; or, it may be, that no tumour may be found. 
Regarded in this light, it appears that the operation has been under- 



464 DISEASES OF THE OVARIES. 

taken 69 times, and that in 30 instances the patient has recovered after 
the extirpation of the tumour. It is true that 43 patients survived gas- 
trotomy, but many of them were subjected to such a fearful operation, 
on the one hand without necessity, and on the other without being dis- 
embarrassed of the disease. 

" Two different plans have been followed in the operation, and it is 
proper to ascertain whether there has been a corresponding difference 
in the results. In the one plan, the incision of the abdominal parietes 
is sufficiently extensive to admit of the removal of the tumour entire ; 
often extending from the ensiform cartilage to the pubes. In the other 
plan, the incision has had the extent necessary for the removal of so 
much of the tumour as would not escape through a puncture, or in- 
cision made in it before the extraction was attempted. If the tumour 
contains little or no solid matter, a puncture might cause the complete 
evacuation of the contents, and the cyst might be removed through 
a very small opening. The author thinks the evacuation before ex- 
traction, and not the exact length of the incision, the important distinc- 
tion between the two operations. 

" The principle of extraction entire has been followed in 44 instances; 
the instances of successful removal by this plan amount to 18. 

" The cases in which the plan of procuring the evacuation of as 
much as was practicable of the contents of the tumour, before the ex- 
traction of the tumour was attempted, amount to 25 ; the instances of 
success to 12. 

" The evidence is then directed to the consideration of the following 

points : — 

" 1st. Can we determine with certainty whether a tumour be ovarian 
or not? If notj have the failures been so frequent as to constitute a 
reason why the operation should not be attempted ? 

" 2d. Supposing a tumour to exist and to be ovarian, can we ascer- 
tain the nature of its contents as well as its connexions? If not, have the 
failures been so many as to be an objection to the adoption of the 
operation at all ? 

" 3d. Are the results of this plan of treatment sufficiently favourable 
to justify us in preferring extirpation to any other mode of treating ova- 
rian tumour ? If so, what plan of treatment promises most success ? 

" The general materials, together with the circumstance that the 
author has been present, either as principal or assistant, in six of the 
operations, have given him peculiar facilities for fairly considering these 
questions; and the conclusions he comes to are, — that we have not the 
means of determining with absolute certainty whether a tumour be an 
ovarian cyst or not, though we think the chances of error ought not to 
be so large as is represented by the tables; that we have no sure means 
of ascertaining the contents and connexions of tumours presumed to be 
ovarian. After an elaborate consideration of the bearings of the third 
question, he says, the aspect in which the question should be ultimately 
regarded is this : the circumstances of the patient's case are so pressing 
that relief must be afforded, and as all other means have failed, it must 
be by an operation. Tapping is usually a successful operation, so far, 
at least, as to afford immediate relief, and in an ordinary case, the pa- 



DISEASES OF THE OVARIES. 465 

tient may reasonably expect to live four or five years, not in comfort, it 
is true, but requiring relief three or five times, as may be, in a year. 
Extraction, though not a very painful, is a dangerous operation ; the 
experience we possess justifies us in the expectation that, in at least 
45 cases out of every 100 the tumour may be extracted, and life saved; 
but at the same time, it must not be concealed, that out of the 69 ope- 
rations to which reference is made, 26 died, and that soon,— in fact in 
a few days. ' 

"If the results already stated should be held to justify the perform- 
ance of the operation of extraction, in cases of ovarian tumours, it 
is incumbent upon us to select the operation which is least perilous 
and painful to the patient. It must be borne in mind that the plan of 
making such an incision as will admit of the extraction entire, was 
employed in 44 cases, and that the recoveries, after extraction, amount 
to 18 cases. The plan of making such an incision as would admit of 
the extraction, where as much as possible of the contents of the tumour 
were removed, was followed in 25 cases, of which 12 recovered after 
extraction. The proportion of recoveries being in the one case 43 
and m the other 48 per cent. The author's own experience is much 
more favourable, being 5 out of 6. It is evident, therefore, that the 
preponderance of success is in favour of what is termed the minor 
operation, that is to say, an operation in which the incision is as small 
as is consistent with the easy removal of the emptied cyst, provided it 
be large enough for the convenient application of the ligature around 
the pedicle." 



CASES OF THE OVARIAN DISEASES. 

MR. WALNE J S CASE. 

Mrs F of- Street, Marylebone, aet. 58, applied to me some time in 

the montn or July with great abdominal enlargement, equalling indeed that of preg- 
nancy at the full period. The catamenia had ceased four years. She used to be subject 
to floodings. Had given birth to five living children, and miscarried several times. 
A rounded prominence of the abdomen, of a circumscribed character, with fluctua- 
tion, and movable as a whole, was found on examination; whilst the health was 
good, and there was no sign of general dropsy present. She had observed her ora- 
dua increase of size for more than two years, and as she could not account for it, had 
lately felt uneasy on the subject, though it caused her no pain, and was, indeed, 
only an incumbrance, and made her unpleasantly remarkable. From scrob cordis 
to pubes was 17^ inches; her circumference was 37£ inches. I pronounced her 
case, on investigation, one of ovarian disease, and after a kw interviews, referred 
her for confirmation of my opinion to Dr. Blundell. Having obtained this, I be^an 
to hint at the means of cure, and having gradually gained her confidence more and 
more, and as gradually intimated my purpose; not concealing from her or her 
i ?7 u VI ^tending the measure: after the cause of postponement above al- 
luded to had been removed, fixed the day of operation, with her ready and full con- 
currence, and enlisted my friendly co-adjutors for the occasion. A few hours before 
the time appointed I went over the steps of the operation with a part of these 
friends ; to one of whom was assigned the charge of the tumour, exclusive of all other 
engagements; to another, that of covering the exposed interior parts by the divided 
skin, the moment opportunity should offer. The temperature of the room was to 



466 DISEASES OF THE OVARIES. 

be raised rather above 70° Fah.; and means were adopted to secure it from change 
in this Tespect as much as possible. A mild dose of aperient medicine, given over 
night, not having acted, an enema, administered half an hour before the time named, 
gave the required relief. 

Dr. Blundell, Mr. Vincent, Mr. L. Beale, Mr. Law, and Dr. Freund, of Vienna, 
were punctual, and between 3 and 4 o'clock, p.m., the patient was placed upon a 
couch, with her feet upon the ground, at its end, and her back supported by pillows. 
Some little preliminary examination having been made, and myself and more fixed 
assistants having taken our posts, myself seated on her right, for the satisfaction of 
all parties I commenced with an exploratory incision of the integuments and tendi- 
nous expansion, and then of the peritoneum, to the extent of an inch and a half. A 
finger was passed on each side into the peritoneal cavity, and the fluctuating cyst 
distinguished quite clearly. No fluid escaped. I now proceeded with the scalpel 
to enlarge the incision from above downwards, including that already made, to the 
length of thirteen inches, or a little more, first in the integuments, avoiding the 
umbilicus, and afterwards in the peritoneum, from the small opening, with a probe- 
pointed bistoury, guided by two fingers of my left hand, upwards and then down- 
wards to the same extent, being from about three inches below the scrobiculus cordis 
to within one and a half of the pubes. This accomplished, the wound began to ex- 
pand on each side, and the tumour to advance gently, but more briskly when its 
greatest bulge had passed through the wound ; demonstrating the propriety of some 
one being appointed for its management, and giving the most satisfactory evidence of 
its being mainly free from unnatural attachment. It had not been ascertained with 
certainty which ovary was affected, but the right was suspected to be the one, and 
so it proved. I now passed two fingers behind the broad ligament, and Mr. Law 
sustained the tumour, which might otherwise have fallen forwards. With a needle, 
having its eye near the point, and fixed in a handle, guided by the two fingers, I 
passed a double ligature behind the pedicle, and thrusting the needle through the 
middle of that part, brought its point forward. The ligature was divided, and dis- , 
entangled from the needle, which was then withdrawn. The tails of the ligature 
being adjusted for tying the two halves of the pedicle separately, I now tied one of 
them, but in doing so the silk broke. The remaining one was used for introducing 
a second double ligature with which the former had to be replaced. After tying the 
pedicle, I divided it between the tumour and the part tied, and, having done so, had 
the satisfaction to see the huge mass of more than 16 lbs. weight lifted from its 
place, and carried away by Mr. Law, no adhesions whatever interfering. I now 
examined the cut end of the pedicle, and tied a considerable artery. At this period 
the patient became very sick, and made repeated efforts to vomit ? but nothing was 
brought up. Dr. Freund had been in charge of the divided integuments, and closed 
them over the abdominal viscera, securing the intestines from exposure to air as 
much as possible. Whilst the retching efforts continued I aided him in this work, 
and my other friends were taking every care of the patient in other respects. When 
these had ceased I ao-ain looked for bleedincr vessels ; but as there was a general 
oozing, rather than any other form of bleeding, it was agreed to tie the pedicle in its 
entire circumference, some notion prevailing that the needle might have severed a 
vessel at a distance from the cut surface. I accordingly did this with double stay silk. 
Bleeding ceased, the wound was cleansed, the other ovary examined by Dr. Blundell, 
and nothing remained to be done but to close and stitch the wound. About a dozen 
of interrupted sutures through the integuments, which had been marked before the 
operation for our guidance at this moment, served to bring the parts together. Long 
pads of lint were laid down each side of the abdomen a little way from the wound, 
and strips of a mild adhesive plaster carried over them from one side of the body to 
the other. A broad bandage, entire at the middle, but slit up into eight roller-heads, 
and previously laid ready beneath her back, was made comfortably tight, and the ends, 
after once encircling her, tied on alternate sides of the patient's abdomen. This 
seemed to give her a satisfactory feeling of security, and drew from her a remark of 
approval. 

At the conclusion of the operation, her pulse was 76, counted by Dr. Blundell : it 
had been exactly that number when reckoned by myself the evening before ; she 
was, however, pale and cold, and when laid in bed requested to have something given 



DISEASES OF THE OVARIES. 467 

to quiet her nerves; a bottle of hot water was put to her feet, she was well covered 
up, and an anodyne administered, with directions to repeat it in an hour: it was 
composed of i gr. Morph. Acetat. and ^iss. Mist. Camph. ; and was so repeated. At 
5 o clock, her pulse was 82. When I visited her at 8, it was 96. She had become 
warm after the anodyne, and having slept two hours, was now perspiring freely 
frrom this time she was neither cold nor had chilly sensation : on wakina from her 
sound sleep, she was at first a little confused, but this soon ceased, and she was ge- 
nerally quite clear and calm in mind. When the pedicle was tied the first time she 
had complained of some pain in the loins, and still more at the second tying of'that 
part; a general smarting of the wound was also, of course, felt. These continued 
between two and three hours, but had now subsided almost entirely. A sensation of 
throbbing succeeded, which also ceased in the course of the night. At 12 o'clock I 
paid her my final visit, and drew off" five ounces of urine. She had slept three 
hours since 8 o'clock : pulse 94 before, 89 after the use of the catheter. No unfa- 
vourable symptoms. 

Nov. 1th.— I visited her at 9 a.m., 4 and 11 p.m., and each time used the catheter, 
withdrawing in all 14* ounces of urine. The pulse at each visit respectively 90, 96, 
86 when asleep, 90 after waking. Having passed a comfortable night, at least 
sleeping great part of the time, she also slept a good deal in the day ; was free from 
pain had no abdominal tenderness, except in the line of the wound, and no distention, 
flatulency, or sickness ; she perspired freely and was comfortably warm. Had taken 
nothing but toast-water, and as too little of this even 'had been given in the great 
caution used to avoid distention from any cause, was rather thirsty in the afternoon, 
but when more was allowed complained towards night that it did not quite suit her 
stomach. Mint-tea was then proposed, but not taken. A spoonful or two of panada 
in the evening was the only thing taken besides, until at night her anodyne of i gr. 
Acetate of Morphine and ^iss. Mist. Camph., was repeated, which relieved the slight 
uneasiness of the stomach. The total abstinence observed throuahout the day was 
in accordance with her own feeling as well as my wish, a* » she°often ate nothino- 
for two days or more when her stomach was out of sorts." 

S*A— The second night was not equally good ; indeed, she had been somewhat hot 
and restless, but still perspiring. The thirst continued, and sickness had twice or 
thrice occurred in the night. Small quantities of soda-water, not in its full activity 
were now allowed, and she took a bottle and a half in the course of the day. I 
visited her four times, and the pulse was noted at each of the visits twice, the ca- 
theter, except at mid-day, being used between making the first and second note. 

9 a.m. 2 p.m. 9 p.m. 12£ P M. 

1st trial 91 92 96 84 

2d do 88 91 92 84 

|iv. of urine withdrawn in the morning. I was induced by this circumstance to 
omit the use of the catheter at 2 o'clock. In the evening 1 received two messages, 
and at 9 o'clock found her very uneasy, with a strong desire to pass urine and stool, 
but afraid to make any effort. The catheter and an enema of warm water afforded 
great relief. Flatus passed from the bowels, and gvi. of urine were withdrawn. 
Vomiting and occasional eructation of wind had occurred. She had changed her 
posture in bed several times, and was not easily restrained from makino- imprudent 
sudden movements in her state of uneasiness. During my 9 o'clock visit this was 
very much the case, and after one of her movements of this kind, she became alarmed 
by feelingsomething hot on the skin of the abdomen. On examination I found serum 
trickling down the skin from the wound. I afterwards suspected that the liaatnres 
which had been left out about two inches from the pubic end of the wound must 
have been pulled a little way within it at this juncture, as the ends were not visible 
when I made my first dressing. Beino very much relieved by what had been done 
for her, and the anodyne having been repeated, at half after 12 o'clock I found that 
three hours of comfortable sleep, and a subsidence of the pulse, had been the happy 
consequences ot the measures. Her mind was clear, and her skin moist all day, but 
after the anodyne warm and perspiring freely, the tongue moist; but vomiting always 
disguises the state of the tongue in that respect, so as to render it almost useless as a 
criterion of the patient's condition. 



^68 DISEASES OF THE OVARIES. 

9th. — Hours of visiting and state of pulse. 



10 A.M. 


4 P.M. 


11 P.M. 


1st trial .... 100 


100 




2d do 97 


97 


92 



She slept two-thirds of the night, and passed, unaided, ^ix. of urine before my first 
visit, and 3vss. after it. Felt a wish for food, and took panada. The sickness had 
ceased. She slept in the day, and again took a little simple food at night. It was 
panada, or something sopped, as biscuit, 1 believe. Complained of slight pain at the 
pit of the stomach. The enema and the anodyne were repeated. Her tongue was 
moist and cleaner, and the skin perspiring. 

10th. — Had two motions from the enema last night, and passed gix. of urine 
twice. Had been somewhat restless and moving, was thirsty, and had occasional 
sickness. Took a cup of tea and a little biscuit for breakfast. Skin moist ; tongue 
moist and brown ; 'some griping pain; passed gxij. more urine in the course of the 
day. The temperature of the room, which had been preserved almost uniformly at 
70°, or a trifle above that degree, and only once before lowered to 67° for a few 
hours, was now reduced to 66°. All this day the pulse ranged from 80 to 82, a fall 
attributable to the free relief of the bowels the previous night, yet some uneasiness 
of a griping kind was now and then felt. Enema repeated ; anodyne conditionally 
ordered, but not taken. 

llth.— She had not had so good a night; vomiting had twice occurred, with 
strong retching, and she had brought up a good deal of bile; there was constant 
nausea, and occasional eructation; gvj. of urine; no motion; occasional griping; 
pulse 80. I dressed the wound, removing all the stitches below the umbilicus, but 
leaving those above that part. 1 directed that some beef-tea should be given with 

salt in it. 

At mid-day the symptoms were not amended. Pulse 83 ; tongue dark-brown, 
and much coated ; her manner drowsy, and her mind at times confused; constant 
nausea, occasional vomiting, and frequent hiccup, with pain at the navel. These 
symptoms made me anxious for her safety. They were those of intestinal distress, 
and reminded me of such as occur in strangulated hernia, and at the ushering in of 
intestinal fever of a bad form. I speculated on the circumstance of the disap- 
pearance of the ligatures, and how they might contribute to the production of the 
symptoms. 1 deemed it useless to search for them, as -their attachment to the pedi- 
cle would render their removal, if found, impracticable ; and after conferring with 
my friends Dr. Blundell and Mr. Vincent, determined to make no attempt of that 
kind, but give the anodyne, then an enema in two hours, and repeat the anodyne if 
necessary.* All this was done. The first anodyne relieved this sickness, procured 
her some better sleep, and revived her very much. The enema produced a discharge 
of flatus and some little feculent matter. She had a tranquil night after ihe second 
anodyne, and on the morning of V2th, felt better ; having passed gxj. of urine in the 
night, and having been scarcely at all sick. Pulse 79, soft and full ; skin warm, 
and freely perspiring; occasional hiccough, which still causes pain at the navel. 
Wished for tea and toast, and took some beef-tea with toast in it. 

Throughout the day she continued to improve. She passed gir. more urine. At 
night the 5 enema, and then the anodyne, were repeated : the former produced a mo- 
tion, which, in part, consisted of a large hard lump of fseces ; her night was good, 
and on the 

13th.— She had neither pain nor sickness, gxvj. of urine passed in as many hours; 
her tongue was moist, and rapidly cleaning, yet the singultus occasionally returned : 
this, she said, she was very apt to experience when well, and was partially relieved 
by sipping water. 1 dressed the wound, removing the remaining stitches : adhesive 
matter was covering those parts of it which were not closed, and which, at three 
points together, amounted to less than three inches. She was cheerful and com- 
fortable al noon, when the wound was dressed, but within a very little time had again 
some nausea and other symptoms resembling those of incarcerated hernia. She 
thought the dressing too tight, and, on raising one end of the strips of plaster, it 
was "found that one of them in particular had been so ; it lay over a part of the wound 
not yet quite closed, where intestine, slightly protected by adhesive matter, was 
liable to pressure. On my removing this piece of plaster she felt sickish and faint, 



DISEASES OF THE OVARIES. 469 

but immediately after much relieved : it had evidently contributed to the renewal of 
unpleasant symptoms; and the circumstance is, I think, one of great practical in- 
terest, for it confirms the observation which the whole circumstances of the case, 
after the completion of the operation, are calculated to draw forth, viz., that it is not 
so much peritoneal inflammation as suffering in the viscera of the abdomen, more 
particularly the intestines, which is to be apprehended as a consequence of free 
incision for the removal of diseased ovarium. 

Having obtained great relief from the loosening and more lightly adjusting the 
dressings of the wound, one other cause of uneasiness and anxiety remained. Several 
hours had elapsed without her having passed her urine, and she felt doubtful of her 
power to do so : the catheter was accordingly used for the last time. The enema 
and the anodyne were also repeated. 

14th.— She had slept well, and at 5 in the morning voided her urine naturally. 
No sickness had occurred; her tongue was clean and moist; pulse 78 and soft; 
passed §ix. of urine in the day, and, except a slight degree of light-headed feeling, 
and a rather violent fit of hiccough in the evening, was comfortable throughout this 
day, and had taken beef-tea, arrow-root, &c, more freely. 

K=. Fel. Bov. gr. x. h. s. s. 

15th.— Passed a tranquil night without the anodyne, and feels quite well ; singultus 
less troublesome ; wished for leave to sit up, but felt weak and languid. Ordered a 
little port wine. 

16th. — Better in all respects : relished some chicken. 

From this time she continued to improve daily. On the 20th, she said she felt as 
if she couid stand and walk, but still had some uncomfortable feeling, and slight dif- 
ficulty in passing her urine. The hiccough did not entirely cease till about this 
time, though it was slight. On 23d, she sat up several hours ; afterwards, when in 
bed, her pulse was 75. On the 25th the ligatures appeared at the pubic end of the 
wound, and on the 27th I removed that which had secured the artery of the pedicle. 
On the 29th she felt quite well ; the wound was healed, except a seton-like opening 
at the lower end of it, where the ligatures were lying, and one point by the umbili- 
cus of redundant granulation of the size of half a pea. It was found requisite to 
give her a mild rhubarb draught occasionally, or sometimes a little magnesia, as the 
bowels did not act with quite their accustomed freedom; but in all other respects 
she was now well, and fast regaining her strength. 

I have not interrupted my narrative of the practical details of the case by any de- 
scription of the diseased part removed by the operation ; and the difficulty I might 
have had in conveying to my readers a correct idea of its character is fortunately 
rendered trifling by the spirited wood engraving executed by Mr. Lee, from his own 
accurate sketch, which he made before any material change in its appearance had 
occurred. 

The greater portion of the mass was fluid, contained in one or more cysts. A 
substance of about the size of two fists, having at some points a scirrhous hardness 
and abruptness of form, occupied that part of the tumour where the remains of the 
Fallopian tube, meamiering towards its fimbriated extremity, sufficiently declared it 
to be the ovarium of the right side, much enlarged and changed in structure. The 
fluid is of the ordinary character of ovarian dropsical fluid, and the solid portion is 
probably of a scirrhous character; but, as I have thought that the disease as nearly 
in its actual form and size at the period of its removal, as it could be preserved, is 
more valuable for the surgical illustration of the subject than when cut into slices 
for pathological ends, as has been done by hundreds such, to which no other history, 
than that of their fatal influence on the frame that bore them attaches, I have not yet 
pursued the ordinary course of destructive investigation with this one; convinced 
that in its present state it suggests useful reflections to those practitioners within its 
reach, whom apathy or prejudice may not prevent from thinking on the important 
question of the curability of certain diseases of ihe human frame by operation; since 
their cure by other means is, by general admission, deemed hopeless. 

But let me not be misunderstood. Let me not be supposed for a moment to re- 
commend this operation as one to be undertaken in any but well-selected cases to 
which it is adapted ; still less let me be supposed to advise that any surgeon should 
engage in its performance who has not, by habits of operating— yet more by long 



470 DISEASES OF THE OVARIES. 

habits of careful observation and treatment of disease crenerally- — and b)' very consid- 
erate ami studious examination of the nature and connexions of this particular disease, 
and the tendencies of the viscera, which may be involved in mischief by an i'l-judgcd 
operation, or ill-conducted after-treatment — qualified himself to cope with difficulties, 
from which it is unreasonable to expect an exemption. 



Case 93. 
reported by mr. eden ; clinical clerk * 

Elizabeth J , Mary's Ward, No. 20: admitted Nov. 1831, under the care of 

Dr. Ashwell ; aged 35 ; unmarried ; subject to irregular catamenia for three years, 
recurring- every fortnight, lasting a week, and accompanied by clots ; ill 16 months. 

On admission — ovarian dropsy; great pain in left iliac region at commencement; 
tumour extends from pubis to ensiform cartilage, and into both iliac fossse ; fluctuation 
distinct; os, cervix, and body of uterus, healthy. 

Treatment. — Nov. 2d; Julep. Pot. Nitrat. 01. Ric. ^ss. p. r. n. — Dec. 18th; 
Elaterii Ext. gr. ss. t. d. sing. dos. mist. 

Prognosis. — Nov. 8th; abdomen fuller; parietes not thin enough to tap. — 29th; 
Paracentesis; ten quarts of dark-green slimy coagulable fluid. — Dec. 6th; left her bed, 
and doing well. — 13th; bandage applied. — 18th; confined bowels. 

Presented. — Cyst slowly filling; to go into the country. 

Dr. Ashwell saw the patient again about eighteen months afterwards; and the 
cyst, although tolerably full, was stationary, and had been so many months. 



Case 94. 

Mary K ; Mary's Ward, No. 12; admitted Aug. 30th, 1832; re-admitted 

March 7th, 1834 ; aged 25 ; married; emaciated, of dark complexion ; miscarried six 
years ago ; ill 18 months ; was first attacked with pain in right ovary ; since which 
a gradual and universal enlargement. 

At present, distinct fluctuation ; cyst very thick at right inferior part ; menses 
regular. 

Treatment. — Sept. 10th; Paracentesis. — 20th, ditto. Purgatives, diuretics, occa- 
sional opiates, and iodine. — March 7, 1834; again tapped. 

Progress. — 15 pints of fluid evacuated. — Sept. 25th ,• again filling. — 29th, 9 pints 
of fluid withdrawn, not coagulable by heat. — Oct. 30th, going on well ; cyst re-filling 
slowly; urine abundant; great constipation throughout. — Dec. 6th, catamenia ap- 
peared after 14 weeks' cessation. — March 7th, 1834 ; 9 pints of fluid withdrawn 
from one cyst only. 

Presented Dec. 1832; again presented, March, 1834. 

In April, 1836, Dr. Ashwell saw this woman, and found the cyst only partially full, 
not requiring paracentesis. 



Case 95. 

Jane B , Mary's Ward, No. 19 ; admitted Sept 28th, 1832 ; aged 67 ; mar- 
ried ; no children; very thin; swelling in both iliac regions for four years. One 
year and a half ago, remained in this ward 12 weeks ; and after a long use of the 

* These cases are reported in this condensed form, that a comparison of similar 
symptoms and points may be easily made, and if 1 am censured for publishing so 
many, my excuse must be, that in this succinct form they occupy but little space, 
and will assist in the construction of accurate statistical tables ; showing the results 
of ovarian dropsies treated without operation. 



DISEASES OF THE OVARIES. 



471 



odine , she diminished nearly to her natural size, from having the appearance of being 
in the last month of pregnancy. Has since attended as out-patient. 

Un admission—abdomen painful, and greatly distended with very firm, fluctuating-, 
ovarian cysts ; abundant urine. For two years after the solid enlargement of the ovary 
commenced there was no dropsical effusion; the fluctuation has only been evident 
during the last 24 months. J 

rrmfm^.-Julep.Iodinii cum Tinct. ejusdem, et Pot. Hydriod. Case, cum Sod. 
Progrm.-Ur.ne abundant throughout; the abdomen much diminished in size; 
giddiness in the head, &c, from iodine. 

Since this period, the iodine has been more or less constantly administered ; and 

ornw» U h nn n ,i T /* JT 1 . restrained from ™Y great accumulation. The solid 
growth on the right side of the lower part of the abdomen is stationary, although still 
01 great size. to 



The following three tables will exhibit a coup d'ceil of the results of almost all the 

?nHpfo?L r M \k en constructed with S reat care and labour by the able and 

lnaeiatigable author. 



Table I.— Cases of Extirpation of the Ovary. 



No. and 

Date. 



2—1809 

3-J816 

4 

5 

6 

7-1821 

8-1825 

9—1825 

10 

11 

12—1829 

13 

14 

15 

16 
17 

18-1836 
19-1833 
20 

21—1836 
22 

23 

24 

25 

26 

27 

28 

29 

30 

31 

32 

33 

34 

35-1840 

36-1841 

37-1842 

38-1843 

39 

40-1643 

41—1843 

42—1843 

43—1843 

44-1844 

45 

46 
47 
48 
49 
50 



Operator. 



L'Aumonier. 
Dr. M'Dowel. 

do 

do 

do 

do 
Dr. N. Smith. 
Mr. Lizars. 
do 

Dr. A. G.Smith. 
Dr.Quittenbaum 
Mr. D. Rogers. 
Dr. Granvjlle. 
Dr. Chrysmer. 

do 

do 
Dr. Ritter. 
Mr. King. 
Mr Jeafferson. 
Mr. DoihofF. 
Mr. West. 

do 

do 

do 
Mr. Har graves. 
Dr. Clay. 



Mr. B. Phillips. 
Dr. Stilling 
Mr. Walne. 

do 

do 

do 
Mr. Morris. 
Mr. Sou ham. 
Dr. F. Bird. 

do 

Mr. Atlee 
Mr. Lane. 
Mr. Key. 
Mr. Greenhow. 
IVj r- B. Cooper. 
Mr. Trustram. 



Age. 



33 
36 
35 
30 



47 



38 



31 
57 

23 



24 

40 
46 
67 
39 
41 
22 
4) 
41 
59 
46 



58 
57 
21 
20 



19 
29 
28 
31 



Incision. 



4 inches 
9 do 
Long. 



3 inches. 
Long. 

do 

do 
About 4 in. 
About 3 in. 

Long, 
do 

do 

do 
Short. 

do 
Long. 
Short. 

do 

do 

do 

do 

27 inches. 
14 do 

28 do 
14 do 



14 
14 
14 



do 
do 
do 



16 do 
16 do 

2 inches. 
6 do 

Long, 
do 
do 
do 
do 
do 

3 or 4 in. 

do 

3 inches. 
Long. 

do 

do 

do 
Short. 



Result. 



Recovered. 

do 

do 

do 

do 

Died. 

Recovered. 

do 

Died. 

Recovered. 

do 

do 

Died. 

do 

Recovered, 

Died. 

Recovered. 

do 

do 

Died. 

Recovered. 

do 

Pied. 

Not cured. 

do 

Recovered. 

do 

do 

Died. 

Recovered. 

Died. 
Recovered. 

Died. 

Recovered. 

Died. 

do 

Recovered. 

do 

Died 

Recovered. 

do 

do 

do 

do 

do 
do 
Diet, 
do 
do 
Recovered 



Character of 
Disease. 


Adhesions 




Abscess of ovary. 




Gelatinous matter. 




Scirrhous ovary. 




Cyst, fluid. 


Adhesions. 




Adherent. 


Cyst, fluid. 




Solid and fluid. 


Adhesions. 


Cart, and larda- 


Adherent 


ceous matter. 




Honey-like and 


do 


green sanies. 




Cyst, fluid. 




do 




do 




Cyst and fluid. 


Adhesions. 


do 




do 




do 




do 




Multiloc. cysts. 


Adhesions. 


Cyst, sol. & fluid. 


do 


do 


Ext. adh. 


do 


do 


do 


do 


do 


Adhesions. 


do 


None. 


do 


Ext. adh. 


do 


do 


do 


do 


do 


None. 


do 


do 


do 


do 


Cystic sarcoma. 


do 


Cyst an 1 fluid. 


do 


Cysts a id solid 


do 


matter. 






Adhesions. 


Cysts, fluid. 


None. 


do 


do 




do 



Cyst, fluid. 



do 



472 



DISEASES OF THE OVARIES. 



Table II. — Cases of Ovarian Disease in which the Operation could not 

be completed. 



Date. 


Operator. 


Cause of Failure. 


R.esult. 


Incision. 


51 


Dr. M'Dowel. 


Adhesions to blad- 
der and uterus. 


Recovered. 


Long. 


52 


Mr. Lizars. 


Solid and very vas- 


do 


do 






cular tumour. 






53—1826 


Dr. Granville. 


Firm adhesions. 


do 


6 inches. 


54 


Dr. Dieffenbach. 


Vascularity. 


do 


Long. 


55—1826 


Dr. Martini. 


Solid and fixed tu- 
mour. 


Died. 


do 


56 


Anonymous. 


Fixed tumour. 


do 




57 


M. Dolhoff. - 


do 


do 


About 6 in. 


58 


Dr. Clay. 


Exten. adhesions. 


do 


Long. 


59 


Mr. Walne. 


do 


Recovered. 


5 inches. 


60 


Mr. Morgan. 


do 


Died. 


Long. 



Table III. — Cases in which the Operation failed from an Error in 

Diagnosis. 



Date. 


Operator. 


Result. 


Disease. 


61—1823 


Mr. Lizars. 


Recovered. 


No tumour found. 


62—1834 


Mr. King. 


do 


do 


63 


M. Dolhoff. 


do 


do 


64 


Dr. Clay. 


Died. 


Uterine tumour. 


65 


do 


Recovered. 


Hydatid. 


66 


do 


Died. 


Pelvic tumour. 


67 


do 


do 


Uterine tumour. 


68 


Mr. Heath. 


do 


do 



Thus the entire number amounts to 68, of which 41 recovered and 25 died — or 
about 1 in 2-|. Of the 49 cases in which the ovary was extirpated — 16 died, or I in 3. 
Of the 9 cases in which the operation could not be completed, 4 died — or 1 in 2£; and 
of the 8 cases where the operation was unnecessary, 4 died — or 1 in 2. 

Age does not appear to have had much influence, beneficial or otherwise, and the 
same may be said of marriage. Adhesions render the result of the operation much 
more dangerous than freedom from the same, and yet not so much so as one would, 
a priori, expect. Where other organic diseases coexisted with ovarian, the termina- 
tion was almost always fatal. It is strange that the operation should have been ever 
performed, where no tumour has existed ; yet the mistake has been made by eminent 
surgeons, and without any negligence on their parts. 

Dr. Monto-omerv mentions a case, where he felt a distinct tumour in a female's 
abdomen, which suddenly vanished in the very act of examination ! The abdominal 
muscles, in fact, often act in such a way as to imitate organic enlargements of the 
liver, spleen, ovaries, &c, and thus deceiveeven the most careful practitioners. After 
many judicious remarks, cautions, and comparisons, our author comes to the follow- 
ing conclusions : — 

" Even after the details I have given, it is very difficult to come to a definite and 
perfectly satisfactory conclusion, because — 1, we have not sufficiently accurate data 
to estimate the progress of the disease unaided by surgery. 2. The cases in which 
ovariotomy has been performed are of such a mixed character, that it is impossible to 
select with fairness those casps in which the operation was demanded for the relief of 
urgent suffering, and suitable to the nature of the disease, without the appearance of 
partiality. And 3, from the obscurity of the diagnosis, it is too much, perhaps, to ex- 
pect that our practice in future will be free from those drawbacks on the operation. 

" But bearing in mind these difficulties, and making allowance for those draw- 
backs, I think we may conclude that there are cases in which the operation would 



DISEASES OF THE OVARIES. 473 

be justifiable; and on these grounds,— we find the general opinion is against the 
curability of the disease by medical means ;— that after a time the patient will die 
from local disease or accident, or constitutional disturbance, and that meantime she 
suffers more or less inconvenience;— that tapping in almost all cases affords but 
temporary relief; — and that, as far as the limited statistics we have adduced are ad- 
missible as evidence, it is attended with great danger: i. e., 1 in 5 died of the first 
operation, and of twenty patients, fourteen (more than two-thirds) died within nine 
months of the first tapping; whilst of the entire number of those who underwent 
the operation of ovariotomy, about one-half have absolutely recovered so far." 

The foregoing paper is very creditable to the industry, the talents, and the judg- 
ment of its author. ° 



Case 96. 

Caroline D , Mary's Ward, No. 18 ; admitted Sept. 6th, 1834, under the care 

of Dr. Ashwell ; aged 27; fair; always healthy; married 10 years; 3 natural 
labours; regular but difficult menstruation ; leucorrhcea ; haemoptysis, from straining 
4 years ago, followed by swelling in right iliac region 12 months after last labour ; 
swelling rapidly increased for 8 months ; then remained stationary till present time ; 
ill 4 years. 

On admission — abdomen considerably distended; fluctuation distinct; pain in 
loins, hips, and left side, on deep inspiration; scanty urine; costive bowels. — 10/^, 
abdomen painful ; now menstruating. 

Treatment.— M.M. earn M.S.— 25th, paracentesis.— 26th, Tinct. Opii. m. xxv.— 
28th, Cal. cum Opio et Liq. Opii sed. 

Progress.— Sept. Yith, distended to the utmost.— 25th, only a few ounces of fluid 
withdrawn, from the compound nature of cysts. Vespere, an immense quantity of fluid 
escaped from the wound. — 26th, better; abdomen distended with air.— 28/A, sudden 
rigours; tightness at scrob. cord.; vomiting of glairy fluid ; burning sensation at 
umbilicus; collapse; cold surface; blue extremities; cold sweats; little diarrhoea, 
but much abdominal tenderness. — 9 p.m., trocar wound gaping and inflamed ; pulse 
like a thread ; sinking. 

Sept. 29th. — Death. No examination could be obtained. 



Case 97. 

Mary M , Mary's Ward, No. 12; admitted Feb. 28th, 1835, under the care 

of Dr. Ashwell ; aged 57; widow; one child 3 years since; catamenia ceased 10 
years ago ; sallow; dark hair and eyes; had good health till within the last year; 
occasional leucorrhcea; severe pain in loins and flooding 6 months since (as much as 
a quart), which occurred every 3 or 4 weeks; constant draining in the intervals; ill 
6 months. 

On admission — a large tumour in the left side of the abdomen extending as high 
as the ribs ; it seems to be divided ; the lower part being very hard, and smaller than 
the upper, which is more extensive, and very movable ; flooding ; difficult micturi- 
tion ; costive bowels ; os and cervix uteri healthy. 

Treatment.— Stimulants, opiates, purgatives, enemata : Croton Oil. Infus. Secal. 
C. o. i. Zinc Sulph. et Alum, aa, ^j. pro injec. 

Progress.— Remarkable for the following circumstances :— flooding ; leucorrhcea; 
tumour pressing on the rectum ; occasional scybalous discharges, at which time the 
vomiting was alleviated ; incontinence of urine ; great pain in the growth; vomiting 
of apparently fecal matter. There can be little doubt that this was°one of those ma* 
lignant growths of the ovary so well described by Dr. Seymour. The fluctuation 
was not sufficiently distinct and extensive to allow of the opinion that it was pro- 
duced by regular dropsical effusion into a scirrhous and indolent ovary. The ra- 
pidity of the progress, and the extreme suffering, confirm its malignancy. 

No examination could be obtained. 



474 DISEASES OF THE OVARIES. 



Case 98. 

Mary S , Mary's Ward, No 15 ; admitted March 21s/, 1835, under the care 

of Dr. Ashwell ; aged 26 ; married 6 years ; 2 children, last, 4 years ago ; menstru- 
ated at 13: catamenia irregular, scanty, and painful; ceased since last child ; good 
general health ; occasional leucorrhcea ; tumour probahly commenced at right side, 3 
years since; continued gradually to increase for six months, when it rapidly became 
large; ill three years. 

On admission, the whole abdomen tense ; umbilicus prominent; fluctuation evi- 
dent; bowels open ; tumour tender ; and at the lower part the fluctuation obscure 
and indistinct. 

Treatment. — March 24th, Vin. Colch. Tinct. Hyosc. Mist. Camph. h. o. o. 
Leeches occasionally. — May 9th, Pit. Hydr. Ext. Aloes. Ext. Hyosc. 

Progress. — Bowels irregular; much the same till May 2d, when she left the 
hospital. Re-admitted May 25th, tumour very painful ; rigours ; burning heat in the 
right side; vomiting of green fluid. Again left the hospital, June Xlth. Re- 
admitted July &th, larger ; suffers from extreme tension; more fluid in abdomen. — 
13th, 3 pints of a glutinous tenacious fluid withdrawn. — 16th, hot skin; thirst; 
anxious countenance; quick pulse; died in the night. 

Inspection — Abdomen only examined; tumour filled three-fourths of the cavity 
interiorly, everywhere adherent to the parietes, and difficultly extracted. Perito- 
neum, with stomach, liver, spleen, &c, presented some traces of old inflammation, 
with abundant products of recent peritonitis : 3 or 4 pints of the mucus of the sac 
found in the serous cavity, mixed with puriform and partially fibrinous matter; some 
surfaces glued together by a plastic effusion ; several parts much injected. Upper 
and larger half of the tumour formed by one immense cyst, with a dense, well-or- 
ganised paries, one-fourth of an inch in thickness, tensely filled with a uniform, thick, 
turbid mucus; inferior part formed a plain wall to the great cyst, and seemed much 
more solid, although apparently forming a part of the main globular or ovoid tumour. 
Section showed it consisted of cells, mostly of the size of an almond, close, and filled 
with mucus ; thin walls, dense, fibrous, pale, rather vascular ; many cells had 
apertures of communication, and the larger ones had others on their inner sur- 
face. One ovary, and broad ligament, thickened and expanded over the tumour; 
uterus enlarged and stretched. Second ovary probably first seat of disease. Bladder 
natural ; liver pale, rather granular. 



Case 99. 

Mary J , Petersham Ward, No. 4; admitted Sept. 13th, 1836, under the care 

of Dr. Ashwell ; aged 30 ; single ; short ; thin ; dark hair and eyes ; born in Sussex ; 
delicate health ; last seven years in Boulogne, as nurse ; catamenia appeared at 14; 
occasional amenorrhoea ; menses occurred every fortnight, five months ago ; ceased 
altogether for the last two months ; ill eight months. 

Her disease commenced with sudden pain in right inguinal region, followed by 
a hard, tender swelling, which rapidly increased, and passed to the opposite side; 
more rapid enlargement and anasarca for the last two months. Now, indistinct 
fluctuation; dulness on percussion; very distended veins; abdomen measures three 
feet six inches above the umbilicus; hardest in neighbourhood of umbilicus; diffi- 
cult micturition ; regular bowels. 

Treatment. — Chiefly diuretics, occasional stimulants, with opiates. 

Progress. — Sept. 23d, abdomen measures 3 feet 7 inches. — 30$, 3 feet 7^ inches. 
CEdema extends to loins ; impeded respiration. — Oct. 4th, 3 feet 8 inches : vomiting 
of dark-green fluid : no nourishment taken. — 10th, 3 feet 8| inches ; — 14th, 3 feet 
9 inches : in the upright posture all night ; bowels confined for some days ; legs very 
cedematous; calf measures I65 inches. — 15th, died at half-past 8 a.m., exhausted. 
She seems to have suffered much from pressure, owing to the unyielding nature 
of the abdominal parietes, hy which the stomach and thoracic viscera were greatly 
obstructed. 



DISEASES OF THE OVARIES. 475 

Inspection.— Each lung the size of two fists, and crepitant; pleura healthy; riaht 
ventricle distended, the valve very imperfect; copious coagula ; abdomen filled with 
a large tumour ; left ovary adherent by a white (Edematous vascular coat; peritoneal 
cavity limited by extensive adhesions; intestines contracted, and coated with old 
vascular, villous, serous membranes; ureters wide, thin, and distended with slightly 
coagulable urine ; kidneys much enlarged, especially the left ; coats easily separated ; 
vertex studded with creamy spots, in different stages of softening ; three or four in- 
flammatory cells in the right kidney; uterus healthy; superior, anterior, and left 
portion of tumour formed of one cyst; its walls, less than one-sixth of an inch thick 
and vascular containing a coffee-coloured fluid, with copious sediment of soft, puru- 
lent fibrin ; firmer sheets coating many parts of the walls, adherent to a deeply ec- 
chymosed lining membrane, which was ulcerating in some situations ; posterior part 
and base of the tumour formed by masses of cysts, and containing fluid of different 
colours. to 



Case 100. 

Juua L— , Petersham and Mary's Ward, No. 1 ; admitted Axis. 13th, 1836 : 

re-admitted Nov. 18th, under the care of Dr. Ashwell ; aged 51 ; Irishwoman ; having 
lved in England 40 years; formerly stout; now emaciated ; nine healthy labours! 
three miscarriages ; good general health; catamenia re-appeared five months a^o, 
after ten months absence, of a menorrhagic character; succeeded by soreness a°nd 
general swelling of abdomen ; ill five months. 

The tumour commenced in the right side, without being perceived ; increased; she 
went into int. 1 homas s Hospital for two months ; and was admitted into Mary's Ward 
this day Right side of abdomen more distended than the left; and occupied by a 
hardened mass, which seems to rise out of the pelvis as high as the ribs; the whole 
of the left side is tense, and fluctuates ; occasional pain and dyspnoea ; much flatulence 
and tympanites; appetite good ; secretions natural. 

Treatrnent.-I3th, Julep. Pot. Nit. t. d. Pil. Papav. cum. Conli gr. v. 0. n.-24*, 
Ung. Iod. audom Pot. Hydr gr. ij. Iod. gr. J. Infus. Junip. gij. Tinct. Card. co. 
3j. t. d.-&p*. If, Acet. Sell. giv. Sod. Carb. q. s. ad saturat. Sumat Coch. ij. 
amp b. d-9*,Jul. Am. t. d. Fotus Papav. p. r. n. Soda Water. Emp. Sinap. 
scrob. cord. r r 

Progress.— 21th, abdomen measures 3 feet 7§ inches.— Sept. 1st, 3 feet 8^ inches: 
urine scanty.-^, 3 feet 10J inches; more painful; more emaciated; respiration 
more difficult.--! lth, anasarca ; upright posture all night ; at 7 p.m. the trocar passed 
two inches below the umbilicus; 10 quarts of thick, glutinous, straw-coloured fluid 
withdrawn ; hard tumour on the right side then felt distinctly; it extends towards 
™VTf ,?'■ an L d u P w ^ rds ' int0 the ri S ht hypochondrium.— 16ft, cyst re-filling— 
19th, 3 feet 8* inches.— Oct. 4th, 3 feet 5* inches.-13*,3 feet 71 inches.-JVw. 18*, 
4 feet; legs (edematous ; considerable dyspnoea; veins enlarged. —22 d, dyspnoea 
very severe during the night. J ' 

Presented. 



Case 101. 

HAi 7n H ?T TT' Petersham Ward > No. 4 ; admitted Oct. 10th, 1836, under the 

care of Dr. Ashwell ; aged 30 ; single ; menstruation regular till within three years ; 
when she caught cold, the discharge became deficient, and her legs swelled ; it ap- 
peared three months ago ; she is somewhat emaciated 

She said, on her admission, she had no recollection of the precise spot where the 
disease commenced ; abdomen measures 3 feet 2* inches an inch below the umbili- 
cus it 11 uniform, slightly projects in the left hypogastrium ; feels like an impreg- 
nated uterus ; very little fluctuation, and that posteriorly; left leg (Edematous ; con- 
fined bowels. J ° 

Treatment-MM. cum M.S. b.d.-24*, Acet. Scill. cum Sod. subcarb. Nov. lst,Cal. 
frrTr t ; gr ',«* al i- noct l T 7 ^Q u i n -Sulph. gr. ij. Ext.Elateriigr.^. Ext. Papav. 
gr nj. t. d.— 25*, Infus. Ros. cum Quin. Sulph. gr. iij. t. d. 



476 DISEASES OF THE OVARIES. 

Progress. — Nov. 7th, much the same. — 15th, the elaterium has produced decided 
benefit; it is only taken occasionally, and causes headache, purging, and sickness; 
abdomen measures 1£ inches less ; and fluctuation slightly increased. — 29th, a dimi- 
nution of3^ inches; urine in good quantity ; no oedema. 



Nov. 10th: Presented. 



Case 102. 



Phcsbe P , Martha's Ward, No. 6 ; admitted June 30th, 1832, under the 

care of Dr. Ashwell ; aged 23 ; an inhabitant of Deal previous to admission ; amenor- 
rhcea for last twelve months ; and impaired general health for about half that time. 

Very little inconvenience till within the last year; since which, the tumour has 
grown rapidly ; fluctuation perceived six or eight weeks since ; prior to this time, the 
growth was quite solid, without the slightest evidence of fluid contents. 

Treatment. — Iodine, internally and externally, and in several forms, continued from 
the date of admission, till Dec. 21st of the same year, when it was permanently omitted; 
and leeches, blisters, refrigerants, and aperients, occasionally resorted to. 

Progress. — More influence exerted over the urinary organs by the iodine than by 
nitre julep: this, however, ceased after nearly six months ; and the iodine then occa- 
sioned head symptoms ; the abdomen, however, had only increased two inches in size, 
and her health was not more impaired. 

Presented, in much the same condition, Jan. 18th, 1833. 

This patient died from cholera within a year after her discharge from the hospital. 
Up to the period of her decease, the tumour had been stationary in size ; nor had the 



softening or fluctuation become more distinct. 



Case 103. 

reported by dr. ashwell. 

Mrs. , aged 35, under the care of Mr. Ranee and myself; married for 16 

years, and has borne five children; of light and strumous aspect; has always been 
delicate, but not sickly ; in her last pregnancy she had ovarian dropsy : and was tapped 
six weeks after her labour; 20 pints of yellow, viscid, and albuminous fluid were 
withdrawn; she recovered, and became again pregnant; ill 2 years. 

Ovarian dropsy, and pregnancy of six months ; few of the usual concomitants of ges- 
tation; she is large and unwieldy ; pulse quick, but not feeble ; embarrassed breath- 
ing, cough, and muco-purulent expectoration; oedema of legs and ankles ; scanty and 
high-coloured urine; debility, and a relaxed condition of the bowels. 

Treatment. — In June, 1836, diuretics, tonics, and alterative mercurials ; nutritious 
diet, mild malt liquor, and carriage exercise. — In August, as there was no marked 
aggravation of symptoms, the plan was not varied. — October 1st, 1836, delivered of a 
healthy boy, and recovery tolerably good. — Till December 11th, paracentesis was 
avoided, champagne and good diet having been largely employed; but at this pe- 
riod, the distention was so painful, the pulse so quick and irritable, and there was 
such entire sleeplessness, that she begged to be tapped ; she measured, round the um- 
bilicus, 4 feet 7 inches; only 2 pints of viscid, dark-coloured, albuminous fluid could 
be obtained, as, unfortunately, only a small and distinct cyst was punctured. — Dec. 
16th. paracentesis, and 3 pints withdrawn. — Dec. 21st, again tapped; this time in 
the linea semilunaris; and nearly 22 pints of the same kind of fluid were eva- 
cuated. 

In a few days afterwards «he sank, exhausted by the disease. (No inspection 
could be obtained.) 

Case 104. 

Ann W , Petersham Ward. No. 7; admitted Oct. 19th, 1836, under the care 

of Dr. Ashwell; aged 38; twice married; one child; always healthy; catamenia 



DISEASES OF THE OVARIES. 477 

absent since June last; inflammation of the lungs last June, for which she was 
rather largely depleted ; after recovery, experienced prickino- sensations over the 
abdomen, for which she went to the Marine Hospital at Woolwich ; ill 8 months. 

On admission— ascites ; abdomen flabby ; tender upon pressure in right hypogas- 
trium and epigastrium; parietes thin ; undulation distinct; bowels costive; painful 
micturition; abdomen measures 2 feet 10| inches, its greatest diameter, an inch 
above the umbilicus, uniform ; considerable oedema of the Ws ; abdomen very tym- 
panitic. J J 

Treatment— Julep. Iodin. t. d. Ung. Iodin. abdom— 24th, Assafcetid. 7A. ex Aq. 
calid o.i. o.n. pro inject.— 27th, Acet. Scill. cum Sod. Carb.— JVov. 1st, Iodin. gr. J. 
Pot. Hydr. gr. ij. lnfus. Junip. gij. t. d.— [\th, Elat. Ext. gr. i ex Infus. Junip. 
t. d.—Uthj 1 lant puncturae. Pil. Ant. Opiat. fort, cum Hydr. submur. gr. ij. quartis 
hons. Hirud. xxiv. scrob. cord.— llth, Infus. Serpent. : cum Amnion, subcarb. gr x 
quartis horis. & 

Progress.— Oct. 19th, abdomen measures 3 feet.— Nov. 1th, pain in back and 
loins ; sickness.— 13th, exposed to wet and cold in the water-closet ; erysipelas 
commenced under the left side of the lower jaw ; cerebral disturbance ; tongue dry 
and black; severe pain in the abdomen.— 1 5th, erysipelas extended to the whole of 
the left side of the face; five relaxed motions; abdomen measures 3 feet 3 inches; 
more dull on percussion.— 16th, erysipelas extended to the right eye; skin of the 
nose suppurating; pulse very feeble, 120; takes no nourishment; died at midnight. 

Inspection.— Nov. Mth, 1 p.m., peritoneum of parietes of a pinkish hue; serous 
surface dull, and a delicate layer of coloured fibrin adherent, but separable, the pe- 
ritoneum beneath being pale and thin, and also separable ; sediment of ascitic fluid 
plentiful, flocculent, and grainy, with large shreddy masses of pus-coloured fibrin; 
liver nodular, and unequally coated with thickened and dense old membranes; kid- 
neys weak, very pale and flabby, and easily lacerated ; cortical texture minutely 
granular ; rather a thick layer adherent to the proper tunic, which seemed thickened ; 
no urine; bladder natural; os uteri thick, solid and coated with mucus; ovaries 
much reduced in size, rugous and dense; jejunum cedematous ; ilium and colon 
covered with minute spots. 



Case 105. 

OVARIAN DROPSY REMOVED BY ACCIDENTAL RUPTURE OF 

THE CYST. 

COMMUNICATED BY DR. ADDISON. 

The subject of the following case was received into the Female Clinical Ward 
of Guy's Hospital, on the 19th of March, 1834. The history, as taken by Mr. Bird, 
Clinical Clerk at the time, is as follows : — 

" Ann Binks, aged 44, a tolerably healthy-looking woman, who has been a widow 
three years, and who has always resided in London, states, that her health has 
usually been very good, till within the last five years. She had one child, 25 years 
ago ; has never miscarried ; and at the present time menstruates regularly. She 
has had some cough almost every winter. Five years ago she first noticed a swelling 
m the left iliac fossa, about the size of an orange, but which rapidly grew larger. 
For this, and for some general anasarca, she was admitted into this ward, two years 
ago. She was, at that time, about the size of a seven months' pregnancy At the 
end of three months, she was discharged, cured of the anasarca ; but still the subject 
of ovarian dropsy, the abdominal tumour, at the period of her discharge, equalling 
the size of a five months pregnancy. She, however, was able to go ou°t to service; 
and continued tolerably well until Monday the 10th instant; when? being entered in 
closing some heavy shutters, and standing upon a pair of steps for that purpose, her 
foot slipped, and she fell ; pulling on her, in the fall, the steps, which struck her across 
the aboomen. She suffered at that moment excruciating pain, became sick and faint, 



478 DISEASES OF THE OVARIES. 

and was then placed in bed, and had medical assistance procured. She now per- 
ceived that the fluid accumulation, which before the accident was circumscribed, had 
spread over the whole abdomen, rising to the diaphragm, and obstructing respiration. 
JShe appears to have then had an attack of peritoneal inflammation ; for which she 
was bled, cupped, and leeched, with some relief; but being unable to perform her 
duties, she applied to be admitted here this day, the 19th of March. On admission, 
her face was pale and anxious, surface cold, circulation languid, abdomen distended 
with fluid ; and she complained of great pain on applying pressure over the abdomen 
generally, but especially over the lumbar and iliac regions. The bowels were open ; 
tongue very red ; she felt thirsty ; her pulse was 98, and small ; urine copious and very 
turbid; and she stated that she had occasionally passed blood by stool since the 
accident." 

It is unnecessary to enter into any minute details respecting either 
the progress or the treatment of the above case. Her symptoms, on 
admission, were those of general peritonitis, and a slight degree of 
bronchitis : for these she was bled to a small extent, fomented, and had 
calomel, antimony, and opium administered internally. Under this 
treatment she improved ; her gums syere reported to be sore on the 
22d, after which the fluid rapidly decreased ; so that on the 5th of April 
there was no fluctuation whatever, and the remains of the ovarian 
tumour could be distinctly traced, stretching across from one iliac fossa 
to the other. 

On the 7th of April, the descent of the cyst, or some other change in- 
duced by the accident, appeared to offer an obstruction to the ascent of the 
blood through the iliac vein ; she had an attack of phlegmasia dolens, 
but by no means severe, affecting the lower left extremity. This was 
subdued, and almost entirely removed in about a fortnight. 

This woman is now, December 1835, servant in a family residing in 
Cheapside ; and although she can still distinguish a small tumour in the 
left iliac region, she has never experienced any return of the dropsical 
enlargement.* 



Case 106. 
reported by dr. ashwell. 

The following case I attended with Mr. Pilcher of the Webb-street School, and as 
it demonstrates the inefficiency of the bougie and injection, the nearest approaches 
to extirpation, I shall very briefly narrate it: — 

Mrs. S , aged 36, the mother of several children, had suffered for some years, 
from ovarian dropsy. Mr. Pilcher had already tapped her six or seven times; and 
on one occasion, after the escape of a large quantity of fluid, an elastic catheter or 
bougie had been left in the cyst, for several days, without producing the slightest in- 
flammation. Mrs. S was very anxious that something more decided should be 

undertaken for her relief: and, after the next evacuation of the cyst, it was injected 
by an enema pump, with several pints of a weak solution of the sulphate of zinc : 
the inflammatory symptoms were alarmingly severe, and her recovery was for some 
days doubtful. Eventually she rallied : but in a few weeks, to relieve excessive 



* This patient was re-admitted into the Hospital in July, 1836, and died in about 
a month. The body was much emaciated, the disease was evidently malignant, and 
the cyst contained about two quarts of dark and slightly offensive puriform fluid. In 
a similar case reported by Dr. Bright, the cyst never filled again, the patient became 
very much emaciated, and died in about two years. 



DISEASES OF THE OVARIES. 479 

* 
tension six or eight ounces were drawn off. The fluid, on this occasion, was not al- 
buminous as formerly, but fetid pus. In a short time, paracentesis was aaain neces- 
sary ; and we were a little curious as to what might be the character of the con- 
tents of the cyst. True pus, slightly fetid, was evacuated, to the amount of eiaht 
pints, not more than a thud of the quantity formerly withdrawn. Tappino- was fre- 
quently afterwards necessary; and in about twelve months she died, completely 
exhausted by the disease. ' 3 

The cyst is in the Museum of the Webb-street School. 



OBSERVATIONS. 

These cases are deeply interesting, as they furnish an illustration of 
many important points in the varying progress and result of the malady. 
In several of them the disease was proved either to have been malignant 
in its commencement, or to have become so during its course, the 
examinations, after death, exemplifying nearly every kind of malignant 
change. Hence, although the accumulation of fluid, the marked feature 
in the majority of the cases, justified the appellation, Dropsy of the 
Ovary ; yet it would in most instances have been exceedingly difficult 
to say, in what precise structure the affection commenced, or what was 
the order in which the component parts of the viscus became diseased. 
But it cannot be denied, looking at the results of several of these inspec- 
tions, that the compound cystic tumour of the ovary resembles carcinoma 
in some points, while it differs from it in others. 

Some of the cases, and others might have been added from writers 
of undoubted authority, show how rapidly patients sink, when accumu- 
lation has reached a certain point, and where, from other circumstances, 
the fluid cannot be evacuated, or only in very small quantity. Nor is 
the result widely different, where the constitution has been alarmingly 
broken down, even if the tapping has been successful. In both con- 
ditions, the powers of life are exhausted, and after, or without the with- 
drawal of the contents of the cyst, the patient quickly dies. 

The cases where re-accumulation and death occurred, after the rup- 
ture of the cyst and the escape of the secretion into the peritoneal 
cavity, deserve careful consideration. 

The varying consequences of tapping, namely the delay in the 
necessity for its repetition, and the continuance of good health after- 
wards, are replete with interest, especially in reference to extirpation. 
Nor is it possible to evade the conclusion, that in those cases, where 
the patient has the best chance of a comfortable and prolonged exist- 
ence, the operation is most likely to succeed ; a circumstance which 
greatly augments the responsibility of recommending so grave and 
dangerous a measure. 

From a perusal of these cases, the contrast is painful between our 
little remedial control over advancing ovarian dropsy, and the good 
which is so frequently obtained from medicine, even in bad cases of 
ascites. Nor can we hesitate to attribute this marked difference to the 
absorbent function of the peritoneum,— a power with which, if at all, 
the adventitious and serous ovarian cyst is only slightly endowed; — for, 
while it can no longer be doubted, after the demonstrations of Dr. 



480 DISEASES OF THE OVARIES. 

Hodgkin, that these lining membranes of the diseased ovary possess 
arteries and veins, it has never yet been shown that absorbents exist in 
their structure. Absorption, I am aware, is not necessarily limited to 
peculiar vessels of this kind ; but still, the pathology of these ovarian 
growths, and the effect of the remedies upon them, tend to the convic- 
tion, that absorption rarely occurs in their cavities. That the internal 
surfaces of these cysts secrete, there can be no doubt, and in this way 
they resemble the peritoneum ; but here the similarity terminates ; for 
while the absorbent power of the latter membrane is undeniable, the 
same function is only partially and doubtfully performed by the adven- 
titious serous membranes. Corroborative illustrations are not wanting 
where, after rupture of a cyst, the fluid of ovarian dropsy has escaped 
into the peritoneal sac, and with or without treatment, has been entirely 
absorbed. 

Hence, too, in the employment of mercury, iodine, and diuretics in 
dropsy of the ovary, we scarcely hope to accomplish more than such 
an increase in the healthy function of the kidneys, as may enable us, by 
counter-secretion, to restrain the morbid ovarian effusion. It will not, 
therefore, be difficult to understand how it is, that we so frequently fail 
in the treatment of these common and painful maladies. 

The statistics of these are instructive. In nine out of the twelve 
patients, there was deranged menstruation. Eight were, or had been 
married, four were single. Two had not been mothers; and the re- 
maining six had produced only twenty-two children ; fifteen of the 
number having been borne by two women ; — facts not altogether unim- 
portant, where the ovaries are structurally diseased. 

Negative treatment, or, in other words, an attention to the general 
health, avoiding, as much as possible, constitutional excitement and 
ovarian irritation, promise most favourably for the patient. The cases 
adduced, and many others, sufficiently attest the inefficiency of medi- 
cine ; and as to the radical cure, it is so truly hazardous, as to be rarely 
even thought of. 

Many patients pass through a long and comparatively comfortable 
life with a large ovarian dropsy; and more might enjoy this immunity 
from suffering, if marriage and parturition were avoided, and if self- 
denial and abstinence were rigidly practised. 

In conclusion, I may perhaps be permitted to allude to a case in 
which the nitrate of silver appears to have restrained the accumulation 
of fluid. A lady, suffering from ovarian dropsy, about whom I was 
consulted by Dr. Petrie of Liverpool, had been tapped several times; 
and when she came to London in June, 1844, there seemed every pro- 
bability that paracentesis would soon again be required. No medi- 
cine was given internally, except an occasional aperient ; but once 
every week I applied the lunar caustic of sufficient strength to darken 
the skin in six or seven spots about the size of a shilling. There was 
sometimes a good deal of pain induced, and in a day or two slight dis- 
charge ; but cicatrization usually occurred in about a week or ten days, 
and then the same process was resorted to. Up to this time (Novem- 
ber), there has been no further accumulation, and the patient's health 
continues good. She is to persevere in the same plan. How much or in- 



DISEASES OF THE OVARIES. 481 

deed whether any permanent benefit will be derived from this degree 
of counter-irritation, it is impossible to say, but certainly no harm has 
as yet ansen from the practice. 



ORGANIC AND MALIGNANT DISEASES OF THE OVARY. 

The ovary may be considerably hyper trophied, all its tissues being 
implicated in the diseased change. Sometimes, however, the fibrous 
coat alone is affected, which I have repeatedly seen in aged women, in 
association with a hardened state of its internal cellular part ; or there 
may be partial thickening of the fibrinous coat around old cicatrices of 
former impregnations; nor is it at all uncommon to find one or several of 
the Graafian vesicles enlarged and hardened, their cavities being more 
capacious than natural, and occupied either with the remnant of ef- 
fused blood or of coagulable lymph. 

These changes are probably exceptions to the fact, that most of the 
enlargements of the ovaries are dependent on malignant disease. We 
have in Guy's Museum a remarkable specimen of solid fleshy enlarge- 
ment of both ovaries. They exceed the kidneys in size, and form per- 
ceptible tumours above the pubes. They can hardly be considered 
malignant, as their structure does not at all resemble any form of such 
affection appertaining to these organs. The late Mr. Stocker has ap- 
pended^ their history the letter which accompanied the preparation, 
and as it is short, I shall insert it :— 

"^ he woman had borne children; and when past the menstrual 
period of life, was seized with pains which were referred to the uterus. 
These continued more or less acute for two months, when a consider- 
able indurated substance was perceptible in the regio pubis; referable 
(as was considered) to a morbid state of tha uterus. After this time a 
difficulty in making water added greatly to her sufferings ; indeed it 
amounted to inability in the erect position of the body; but the recum- 
bent posture sensibly removed the only impediment to its discharge. 
From anxiety, which her intolerable pain induced, or from a combi- 
nation of circumstances, she became the most emaciated object I ever 
witnessed. Jaundice supervened, attended with ascites; and in this 
precarious situation, some one, being consulted, took up the idea of its 
being a scirrhous liver, and recommended a moderate ptyalism to be 
raised and supported. The hardened substance before mentioned was 
considered by him as a continuation of the liver. Mercury, however 
was only given in small quantity ; and soon after she began its use! 
death closed the scene. 

" I solicited an examination of the body, and have sent you the en- 
larged ovaries. The liver was perfectly sound." 



482 DISEASES OF THE OVARIES. 



ATROPHY OF THE OVARIES 

Is probably more common than has been supposed (vide p. 375), 
although amongst a large number of preparations of ovarian diseases, 
in the Museum, we have scarcely any demonstrating this state. There 
is one, however, presented by Sir Astley Cooper (2223), " two bodies, 
which appear to be ovaries, very much wasted, and enveloped in fat." 
Lately in the body of a lady who had been long married without ever 
having been pregnant, I found the ovaries hard throughout, their inter- 
nal structure entirely destroyed, their fibrous coat almost of cartilaginous 
induration, and their size did not exceed that of a large horse bean. 
This patient had suffered from dysmenorrhcea and amenorrhoea all her 
life. 



FIBROUS TUMOURS OF THE OVARIES 

Are occasionally found, sometimes in association with the same form 
of disease in the uterus ; more rarely existing independently, either 
attached to, or imbedded in the proper substance of the organ. 

These tumours may acquire immense size ; and in an out-patient of 
Guy's, long under my care, the abdomen was half filled by what I be- 
lieve to have been only a fibrous enlargement of this organ. There 
was scarcely any pain, although she suffered much prior to its ascent 
above the pelvis, from pressure on the bladder and rectum, and from 
very frequent nausea. Jt wanted the stony induration of scirrhus, and 
there was never, while she was under my care, any fluctuation, or any 
"softening indicative of malignancy. She was not emaciated, nor, ex- 
cepting when menstruating, was she disqualified for her domestic duties. 
Happily she never became pregnant after the appearance of the tumour; 
and when, at the age of 40, she left London to reside in Scotland, the 
tumour was quite stationary, and she appeared as likely to live as any 
other person at her period of life. 

Professor Simpson has a specimen, taken from a tumour in the 
ovarian region, that weighed 56 pounds. It had been first observed 
about 20 years previously to death, in the right iliac fossa. It was 
then of the size of an egg, and had gradually increased from that period, 
till at last it rose as high as the diaphragm, and compressed even the 
cavity of the chest. The circumference of the abdomen after death 
was 5 feet 4 inches. The tumour was quite movable within the abdo- 
men, and was only attached at two points, namely, by a few old cellu- 
lar adhesions to the larger omentum, and by its original pedicle to the 
right broad ligament in the site of the ovary. This last organ was ap- 
parently incorporated with the morbid mass, or at least was not visible. 
The uterus was healthy. In one portion the tumour was softened and 
disorganised, probably from compression of the vessels of that part, 
and consequent gangrene. 
Cruveilhier remarks, that fibrous tumours of the ovary are so per- 



DISEASES OF THE OVARIES. 483 

fectly identical with those found in the uterus, that it is impossible to 
determine to which of the organs they have belonged. 

Dr. Baillie entertains the same opinion, and says, " The ovarium is 
much enlarged in size, and consists of a very solid substance, inter- 
sected by membranes which run in various directions. It resembles in 
its texture the tumours which grow from the outside of the uterus, and 
I believe has very little tendency to inflame or suppurate." Examples 
are not wanting, where these fibrous tumours of the ovary have dege- 
nerated into structures of cartilaginous and osseous hardness ; thus pre- 
serving their resemblance to fibrous uterine growths. Generally there 
are only small portions of these substances deposited ; and in a prepara- 
tion in Guy's Museum, there is a patch of calcareous matter underneath 
the external coat. 

It is by no means improbable, that some of the larger growths men- 
tioned by authors, were not fibrous but scirrhous. Scrofulous and 
tubercular degeneration of the ovaries may be reckoned amongst their 
rarest diseases. 

Amongst the causes of these tumours may be enumerated, peculiarity 
of constitution (a very inexplicable yet comprehensive term), falls, pres- 
sure and blows ; although in most cases it is difficult to discover any 
specific or positive cause. 

The symptoms are rarely more than mechanical, as fibrous tumours 
are seldom attacked with inflammation. But while confined within 
the pelvic cavity, they may seriously derange the functions of the blad- 
der and rectum ; and either, while in this situation or when, from their 
size, they have risen higher, they may from their pressure occasion par- 
tial paralysis or numbness of one thigh and ]eg, and even oedema. 

I have already explained what is to be done when a growth of this 
kind complicates labour; but, generally, when of large size, it inter- 
feres but little with the patient's comfort or the duration of life. 

The diagnosis, between fibrous and scirrhous growths, is sometimes 
difficult, but the slow progress, good health, and freedom from pain will 
usually enable us to distinguish between these tumours and malignant 
disease. An examination per rectum will prove, if it be not large 
enough to occupy considerable space in the pelvic cavity, that it is 
ovarian, not uterine. 

The treatment (where the tumour has not risen above the pelvic 
brim) is limited, for the most part, to relief of the mechanical inconve- 
niences by the catheter and aperient injections. Afterwards it is best 
to leave it entirely alone, excepting inflammation occurs, when, of course, 
local antiphlogistic treatment must be employed. 

MALIGNANT DISEASES OF THE OVARIES. 

Scirrhus of the ovary is thought by many pathologists to be more 
frequent than cancer of the breast, and almost as common as cancer of 
the uterus. Although my experience does not confirm this opinion, 
especially the latter part of it, I acknowledge, that malignant dis- 
ease of the ovaries is not unfrequently met with, and I have nar- 
rated a case where scirrhus of both ovaries destroyed life before the 



484 DISEASES OF THE OVARIES. 

18th year. In this instance, the disease in both the organs was of large 
size, tuberose, and exceedingly irregular in shape. For six months 
before death there was amenorrhoea and excessive leucorrhceal dis- 
charge. Only palliative treatment was recommended, the extent of the 
disease forbidding active interference. A post-mortem examination 
confirmed the opinion, that the uterus was* perfectly healthy, and that 
the ovaries w T ere entirely scirrhous, so much so as to have obliterated 
every trace of their natural organization. In this instance no softening 
had taken place ; but such a change is not uncommon, and true scir- 
rhus may coexist in the ovary with fungus hsematodes, or cerebriform 
disease. 

Dr. Baillie saw a case where softening had commenced, the affection 
being coincident with cancer of the stomach. The preparation is in the 
Museum of the London College of Physicians. 

Nauche says, " Cancer may be developed in the ovaries, and run 
through all its stages. Occasionally it is hard and scirrhous, acquiring 
double or triple its ordinary volume ; in others, it is in a state of latent 
suppuration, terminating by ulceration. There form, in the neighbour- 
hood, dilatation of the veins, and a deposition of cartilaginous and os- 
seous substance." 

In fungus hamatodes, encephaloid or cerebriform disease, there is con- 
siderable variety of structure in the same diseased mass. Thus, in one 
part of such a growth there may be portions of fibrous, cartilaginous, or 
even calcareous hardness; while, in juxtaposition with these, may be 
fungous, carcinomatous or melanotic productions, full of cells containing 
fluids of various colours and consistence. The preparations in Guy's 
Museum fully elucidate these extraordinary complications of malignant 
ovarian disease.* 

* Seymour's Illustrations, plates 12, 13, 14— pp. 66, 70, l\. See also Bright's 
Cases and Drawings of Ovarian Diseases in the 3d vol. of Guy's Hospital Reports. 

Dr. Seymour ha's described two varieties. The first consists " of numerous cysts, 
•with more or less fluid contents, sometimes with bony or earthy matter contained in 
them; often a fatty secretion, resembling lard ; sometimes penetrated with long fine 
hair, without bulbs ; but more frequently filled with albuminous secretions of vary- 
ing tenacity and colour. Sometimes these secretions resemble gruel in appearance: 
there is often matter like soot mixed with the fluid. At other times, the secretion is 
of the colour of mahogany from admixture of blood ; and not unfrequently the liquid 
evacuated from one of these cysts, by the trocar, resembles, in consistence and colour, 
the medicine well known under the name of Griffith's mixture. 

"Secondly, a single large cyst springs from the ovarium, and contains within it 
tumours varying from the size of a pin's head to that of an orange. Sometimes the 
great portion of the parietes of the cyst consists of tumours, growing between the 
external and internal or secreting coat, the interior of the cyst having the tumours 
projecting into it, being filled with fluid secreting from the serous lining. The tu- 
mours, when cut into, present a semi-fluid gelatinous substance, with white bands 
running through it, between which bands are smaller cysts, containing the same 
viscid, glue-like matter." 

"Sometimes these masses are formed of fibrous, cartilaginous, or osseous tissue; 
in other cases, they are almost entirely composed of encephaloid matter. The walls 
of the cysts are thick, and their cavities gradually enlarge until a tumour is formed, 
which fills not only the epigastrium, but the whole abdominal cavity. The outer 
surface of the tumour is unequal ; in some points a fluctuation can be felt, while in 
others it has a hardness and density equal to bone." Precis. d'Anat. Pathol, vol. 
iii., p. 708, Andral. 



DISEASES OF THE OVARIES. 485 

Dr. Lee's observations are confirmatory of these opinions : he says, 
"The ovarium is sometimes affected with encephaloid disease, or' is 
converted into a large irregular-shaped mass of cyst and tumours, the 
section of which presents all the characters of haematode fungus." 

There is great variety in the size which these malignant productions 
attain. Sometimes they remain of moderate dimensions, not exceeding 
perhaps the bulk of the adult head, but there are cases recorded, and 
such I have seen, where the bulk was much greater ; and Boivin men- 
tions a case of encephaloid cancer of the left ovary which weighed 
seventy-five pounds. 

Sometimes in the development of these tumours, dilatation of their 
cavities occurs ; arid from becoming partially filled with fluid, obscure 
fluctuation may occasionally be detected. I have several times been 
struck with the rapidity of their progress, and in a case of truly malig- 
nant affection I lately saw, not more than five months elapsed between 
the first appearance of the tumour in the right groin and the death of 
the patient, the growth having in that short time acquired' enormous 
bulk. It is not uncommon, however, even for these diseases to remain 
in an indolent state for some weeks or months, and then an attack of 
inflammation, abscess or partial dropsy may occur in some portion of 
their structure, and rapid progress consequently becomes apparent. 
Adhesions to neighbouring organs, especially if the disease has not 
risen out of the pelvis, may seriously interfere with the patient's com- 
fort by deranging the functions of the bladder or rectum. 

It is difficult to assign satisfactory causes. Pregnancy and labour 
may hasten the progress of these diseases, but as virgins are liable to 
the same maladies, these conditions cannot be regarded as extensively 
influential in their production. 

Blows or falls, and excessive pressure from tight-lacing, or indeed 
any circumstance provocative of chronic ovarian inflammation, may 
lead to the development of the disease. 

Symptoms. — Neither menstruation nor conception are interfered with, 
so long as one ovary, or even a portion of one ovary, remains sound. 
Already I have described the danger and the treatment to be pursued, 
where parturition is so complicated. 

It is not often that any changes take place in the state of the tumour 
itself, till, having risen out of the pelvic cavity, softening occurs; when 
severe pain, rapid exhaustion, and malignant cachexia terminate the 
patient's life. Dr. Seymour observes, " The malignant form of the dis- 
ease may be recognised during life, by the want of nutrition, and broken 
health of the patient, the uneasiness and rapid growth of the tumour, 
the simultaneous enlargement of glands in other parts of the body, and 
the occasional occurrence of lancinating pains in the parts. The latter 
symptom is not constant. The pulse is quick and feeble, and as the 
disease proceeds there is hectic fever, and often aphthae in the mouth, 
with an inexpressible sense of debility." 

It is not uncommon for effusion to take place into the abdominal 
cavity, from increased action in the peritoneal membrane, although the 
period may be comparatively long between the first recognition of the 



486 DISEASES OF THE OVARIES. 

disease and the development of the constitutional symptoms, it is certain 
ultimately that fever, quick pulse, and deranged stomachic functions, 
will lead to emaciation and death. 

Treatment.'— This is very limited : active medicines, as iodine and 
mercury, are worse than useless after the early stage ; and if at any 
time pushed too far, will induce irritation and debility. 

Soothing, palliative measures are alone proper, and whether by ex- 
ternal fomentations, or internally narcotics in some of their various 
forms, will be eventually our only resource. 



CHAPTER VIII. 

ON THE DISEASES OF THE EXTERNAL ORGANS OF GENERATION IN 

THE FEMALE. 

The external genitals of the female are the occasional seat of a 
variety of disorders. As organs of copulation, they may be infected 
with syphilitic disease, and are exposed to physical injury from too fre- 
quent or forcible sexual intercourse. The great distention which they 
undergo during the last stage of labour, and the severe and long-con- 
tinued pressure to which they are then liable, occasion lacerations, 
contusions, and inflammations, whilst their external position leaves 
them so far unprotected, as to subject them to accidental injury from 
blows, falls, kicks, &c. They include, too, a variety of elementary tis- 
sues, which carry with them their peculiar lesions ; whilst their great 
vascularity, and their venous plexuses, add another source of local dis- 
order. They are associated by direct continuity with the internal organs 
of generation ; and hence the uterus often becomes implicated in a 
secondary way, and the general health eventually impaired. Their 
peculiar sensitiveness is morbidly manifested in the great suffering 
which attends their diseases ; and, as they form the outlet of a very 
extensive mucous membrane, diseases which are established in a re- 
mote portion of the sexual or urinary organs, are not unfrequently felt 
at this, their peripheral extremity. Great importance, too, is imparted 
to these diseases from the fact, that irritation of the clitoris or nymphae 
is apt to provoke venereal desires, which occasionally affect the mind, 
and induce a most painful form of insanity. 

Amongst the particular diseases of the external organs of generation, 
the first to be noticed is — 



PHLEGMONOUS INFLAMMATION OF THE LABIA. 

The external labia, like other analogous tissues of the body, are 
sometimes affected with acute inflammation and abscess. One labium 
only is usually attacked, and females of all ages, both married and 
single, are its subjects. The range of causes which may excite it is 
very extensive ; but a larger number of them belongs to the married 
than to the single. Although the external organs are, from their posi- 
tion, well defended, yet falls and blows occasionally reach them, and 
inflammation and its consequences supervene. Sometimes the labia 
inflame and suppurate spontaneously, that is, without any apparent 
cause ; and this is, especially, the case during pregnancy. More fre- 



488 DISEASES OF EXTERNAL ORGANS OF GENERATION. 

quently, however, abscess is caused from the irritation of sexual inter- 
course indirectly or violently performed ; and particularly when mar- 
riage has been prematurely contracted, these organs being tender, 
susceptible, and imperfectly evolved. Acrimonious discharges from 
the uterus or vagina, dysmenorrhea, and exposure to cold during men- 
struation, may severely excite this complaint. 

A sense of fulness, with pain and irritation of the labium, greatly ag- 
gravated on sitting down or walking, are the first indications. The 
part becomes swollen, hot, and red ; and, as suppuration goes on, the 
pain is throbbing and severe. Sometimes the abscess is small and de- 
fined, and points to the inner surface of the labium ; at others it is large 
and diffused, and burrows deeply in the surrounding structures. The 
nymphae open to accommodate the increasing abscess, and the glands 
in the groin are sometimes sympathetically enlarged. An increased 
mucous discharge from the vagina, with sacral and lumbar pains, add 
to the suffering. When the inflammation is acute, suppuration is estab- 
lished in 24 or 48 hours ; but sometimes, being indolent, a slough 
forms below, and the lonal disorder is ill-defined and tedious in its cure. 
During the progress of suppuration there is much attendant fever, and 
even delirium has occurred. 

There can be little doubt that phlegmonous inflammation of the la- 
bium would be frequently resolved, were patients to seek advice before 
suppuration commenced ; but this is rarely the case. The attempt, 
however, is sometimes successful, w T hen the softening is still indistinct. 
The patient should be kept strictly at rest, and from eight to a dozen 
leeches applied over and around the swollen part ; and the bleeding 
must be encouraged by the constant use of a sponge dipped in hot 
water. When the congested vessels are thus relieved, a cold spirituous 
lotion may be applied over the part ; or it may be advantageously sup- 
ported, or gentle pressure applied by means of a well-adjusted T band- 
age. The bowels are to be briskly purged, and saline medicines, with 
15 or 20 drops of antimonial wine, ought to be administered every four 
or six hours. When matter has formed, it may become a question 
whether the abscess ought immediately to be opened, or allowed to 
point and discharge spontaneously. For my own part, I am disposed 
to think, if the abscess is circumscribed and advancing quickly to the 
surface, it heals more quickly and kindlier when unassisted with the 
lancet; but if it be large, diffused, or indolent, or the patient's suffer- 
ings very severe, we may abridge the latter, and expedite the cure of 
the former by freely opening it. When this is accomplished, a poultice 
made with bread saturated with hot poppy decoction, will afford much 
relief. Sometimes the matter may burrow, and the sinuses thus formed 
greatly impede and protract the healing. Division by a bistoury, and 
the use of nicely arranged pressure, will suffice for their cure. 



ENCYSTED TUMOUR OF THE LABIUM. 

Simple, single cysts are occasionally developed in the labium. They 
consist of a sac containing a transparent glairy fluid, which grows 



DISEASES OF EXTERNAL ORGANS OF GENERATION. 489 

slowly, and without much pain. The cyst, owing to injudicious hand- 
ling, sometimes inflames, and its contents are converted into a semi-puru- 
lent thin matter, tinged with blood. A good deal of irritation is set up 
in the vulva, and the feeling of simple enlargement and fulness, which, 
at first, was alone felt by the patient, is now aggravated by heat and 
shooting pains, and tenderness on walking or sitting down. On exa- 
mination, the labium is found swollen, but soft and yielding to the touch ; 
and although sometimes the cyst may be defined beneath the skin, in 
general it is too diffuse and impressible to be so. The integument is 
unaltered in colour, and the absence of local action readily distinguishes 
it from an abscess. I have known much difficulty arise in the diagnosis 
of this tumour from hernia. Both diseases may occupy the same po- 
sition, and the same soft elastic feel is perceived in both. On careful 
examination, however, the distinctive signs of the more serous disease 
are absent. The cyst does not swell and distend under the action of 
coughing, nor can it be traced either into the abdominal ring, or the ca- 
vity of the pelvis, as is the case both in inguinal and pudendal hernia.* 

These cysts are not to be removed by external application ; neither 
iodine nor blisters will promote their absorption. They may be punc- 
tured with a small trocar and the fluid withdrawn from them, and the 
cyst may sometimes be obliterated by its sides being held together by 
means of a pad and bandage. It may also be entirely dissected out; 
or made to suppurate by a free opening in it ; or by the insertion of a 
seton. Either of these means may be relied on for a cure. 

The labia may be unduly enlarged as a natural formation ; or they 
may become hypertrophied ; or large growth, of a sarcomatous or stea- 
tomatous character, may be connected with them. These latter tu- 
mours sometimes become very voluminous, depending from the labium 
and hanging between the thighs. They are to be removed by the 
knife. 

Under the designation of oozing tumour of the labium, Sir C. M. 
Clarke has described an affection of this part, whose distinctive and 
prominent symptom is a copious watery discharge. It is a rare dis- 
ease, and attacks females who have passed the middle period of life, 
and whose constitutional powers have been impaired from too frequent 
child-birth, or exposure to any other depressing causes. One labium is 
usually affected ; but the other may be irritated into a similar action by 
the discharges from the first, and it may extend to the mons veneris. 
The labium is not in this disease converted into a large pendulous or 
prominent tumour ; but its tissue is raised and extended, and its sur- 
face rendered irregular from a number of projecting elevations. When 
emptied of the fluid which runs from it, it still remains hard, and does 
not sensibly diminish in size. The discharge arises from furrows on its 
surface, without vesicular disease. In structure it appears to resemble 
the oedema durum, although the watery secretion is a peculiar addi- 
tional sign. Sir C. Clarke has never seen a similar affection of the 
skin in other parts of the body. Some years since there was a female 

* A lady was lately placed under my care by Mr. Addison, of Burnham, where the 
diagnosis was not certain, till an exploratory puncture gave exit to some glairy 
mucus mixed with blood. 



490 DISEASES OF EXTERNAL ORGANS OF GENERATION. 

in Guy's Hospital, whose abdomen was very much enlarged from an 
enormous increase of the cellular membrane, which was firm, hard, and 
massive. Here and there, however, some largish vesicles were raised 
on the surface, from whence copiously exuded a clear transparent 
serum. A model of the abdomen with a drawing, are in the Museum. 
I am disposed to regard this case as similar in character to the oozing 
tumours of the labium, exhibiting a like action in the cellular tissue, 
and occupying a very extensive surface. The accompanying symptoms 
are at first but slightly marked ; and females are often willing to en- 
dure them rather than seek advice. As the fluid, however, increases 
in quantity, and bathes the surrounding textures, they become irritable 
and excoriated, and occasion much local suffering. Hence smarting 
and shooting pains about the inner side of the labium, with a general 
sense of heat in the external organs, and pain and heat in passing 
water, become troublesome symptoms. If the general health is much 
disordered, the fretting to which the mucous membrane of the vulva is 
exposed, may excite a state of erythema, which greatly aggravates the 
patient's sufferings. 

This condition of the labium is not much under the control of re- 
medies. Contrivances to imbibe the fluid as it exudes, and prevent 
its running over the adjacent parts, are important. Lint, moistened 
with cold water, or a weak solution of alum or sulphate of zinc, 
covered with oil-silk and supported by a bandage, will be found to 
give relief. Spirituous washes too are useful. Powdered starch, or 
flour, or fuller's earth act as absorbents, and defend the part from the 
action of the air. 

More real benefit, however, will be obtained by a close attention to 
the general health. Removal to a dry, bracing atmosphere is a matter 
of much importance ; for the amount of discharge has been observed 
to be increased during damp weather. Sea-bathing or a hip-bath of 
bay salt and water may be prescribed. A nutritious diet, with a mo- 
derate quantity of stimulants, will aid much in establishing the impaired 
strength of the patient, and with these, chalybeates or the vegetable 
tonics may be beneficially associated. Should such means fail to check 
the discharge, and the fear of impending danger, or impatience of the 
inconveniences caused by the complaint urge the patient to demand it, 
the diseased labium may be cut off. This was done in a case related 
by Sir C. Clarke : the wound granulated kindly, and the patient perfectly 
recovered. 

WARTY TUMOURS OF THE VULVA. 

The external genitals are liable to warty tumours, which vary much 
in their appearance and size, as well as in the symptoms which attend 
them. They are frequently the result of syphilitic disease, or they may 
arise from neglect of cleanliness. Sometimes there is no evident cause ; 
but they are apt to be induced by any disorder which keeps up a chronic 
inflammatory action in the sexual organs. They may attack the labia 
or nymphae, or beginning at either, may extend to and involve the other 
parts of the vulva. In some cases we see these warty tumours growing 



DISEASES OF EXTERNAL ORGANS OF GENERATION. 491 

slowly, and elevating the labium into a swelling, which, from being 
the size of a nutmeg, may become a large body weighing a pound or 
two. During their increase, the patient experiences little else than 
mechanical inconvenience. The firm, hard substance of the growth 
impedes progression, and interferes with the sitting posture. The labial 
integument becomes hard, thick, and corrugated, and the surface of the 
growth uneven and nodulated. The tardy increase of these tumours 
is sometimes suddenly changed for one of greater activity, and with an 
absolute enlargement of them, ulceration takes place in some part of 
their surface. This is followed by a copious fetid discharge, of so 
acrid a kind as to irritate and inflame the neighbouring structures. 
When this occurs, the general health begins to suffer, and the ulce- 
ration assumes a very unhealthy character. Warty growths spring often- 
times from the more vascular structure of the nymphae, beginning as 
small, fungating, highly injected bodies, several of which coalesce and 
sprout up rapidly. Sometimes they cluster around the urethra, or are 
attached to the vestibule or clitoris. This form of warty growth is of 
soft structure, readily bleeding, and attended frequently with exquisite 
sensibility. It excites a good deal of leucorrhcea, and a fetid discharge 
accompanies it. 

When the warty tumours of the labium have arrived at any magni- 
tude, and especially if ulceration has taken place, the only available 
cure is the excision of the entire growth. I have seen this done in 
several cases, where the tumours were very large ; and although much 
hemorrhage succeeded, yet pressure with cold or styptic applications 
controlled it. We may frequently succeed in getting rid of the softer, 
fungating warts, by the application of savine powder, or by the con- 
tinued use of the nitrate of silver. If they are pediculated or sufficiently 
raised, a ligature of silk twisted round a bunch of them, soon destroys 
their vitality by arresting the circulation ; and their reproduction may 
be prevented by the lunar caustic. Powdered opium sprinkled around 
their base will frequently destroy them. Should they be in any wav 
connected with a venereal origin, mild mercurials with tonics will be 
necessary. The liq. hyd. bichlorid., with dec. and ext. of sarsaparilla 
and dec. of bark, is a valuable combination for the purpose. 

INFLAMMATION OF THE MUCOUS MEMBRANE OF THE VULVA 

Assumes various forms : sometimes it is diffused throughout it, as in 
erythema or erysipelas or the catarrhal affections of this portion of the 
genito-urmary tract. Not unfrequently it is attacked with a vesicular 
disease, as eczema ; at others, with a papular one, as prurigo. Besides 
these, an aphthous inflammation of the vulva, extending along the 
vagina and ulcers of different kinds unconnected with syphilis may be 
noticed as belonging to the inflammatory affections of these structures. 
Several of these disorders, from the intense local irritation which they 
occasion, have been grouped together under the descriptive title of 
pruritus; but as this term designates only a symptom, while the dis- 



492 DISEASES OF EXTERNAL ORGANS OF GENERATION. 

eases differ essentially from one another, we prefer subdividing them 
more accurately. 

The entire mucous lining of the vulva may be attacked with acute 
inflammation, resembling the catarrhal form of inflammation in other 
mucous structures. It is a disorder which is often seen in young chil- 
dren, and is frequently excited in adults. It has been noticed to occur 
epidemically amongst the former, and the description of it by Mr. 
Kinder Wood, in the 7th vol. of the Med. Chir. Transactions, is full of 
interest, and most graphically pourtrays a frightful disease. Cases, 
however, such as those alluded to, have never fallen under my notice ; 
and while I have seen more instances of a much milder form of" this 
disease at one time than another, yet they have never been sufficiently 
numerous or connected with a particular locality to induce me to regard 
their occurrence as any other than casual ; and certainly not to ascribe 
them to an epidemic influence. In the epidemic in Manchester in 1815, 
described by Mr. K. Wood, the pudendal affection was preceded for 
three days by pains in the head, and much disorder of the stomach and 
bowels, with chilliness and great general depression. The swollen 
labia assumed a livid aspect; and gangrenous inflammation, with a 
copious fetid acrimonious discharge, destroyed the parts ; and in ten out 
of twelve cases the children died. Boivin and Duges have descirbed 
cases of phagedenic ulceration occurring epidemically, where the ulcers 
in the vulva of some of the children attacked, who were of a weak 
cachectic frame, presented all the characters of wounds affected with 
'hospital gangrene. So far as I know, this character of disease is not 
seen in London; but a mild, and in general a manageable inflammation 
of the pudendum, is not unfrequently met with in children of all ages. 
In infants, a neglect of careful washing, increased amongst the poor 
and destitute by unwholesome and insufficient food, constipation of the 
bowels, and exposure to cold, are common exciting causes. I have 
frequently observed it come on during painful and difficult dentition, as 
one of many local expressions of the irritation which then pervades the 
integument and mucous membranes. Sometimes the accumulation of 
the thread-worm in the rectum, and their occasional presence in the 
vulva, having crept from the bowel, originate much irritation there, 
and give rise to this affection. 

Attention is first directed to these parts by the pain and dread which 
the child experiences in passing water, and the frequent attempts to 
relieve the irritation by rubbing them. This is particularly seen when 
the bladder is full, and the fear of the smarting pain induces an attempt 
to postpone the evacuation of the urine. On examination at the outset 
of the disease, the mucous lining of the vulva, especially around the 
prepuce of the clitoris and the vestibule, is swollen and much injected ; 
and in a short time a clear mucous discharge succeeds and relieves the 
dryness which first attended it : the constitutional symptoms are gene- 
rally inconsiderable, although I have sometimes known them to be very 
distressing. It is difficult, however, to say how much of the distant 
sympathy of the stomach and brain, which is occasionally seen accom- 
panying this disease, depends on the other attendant disorders, whether 
of dentition, or ascarides, or general cachexia. Frequently, however, 



DISEASES OF EXTERNAL ORGANS OF GENERATION. 493 

the rectum partakes in the irritation of the adjacent parts, as evinced 
by frequent small stools with much tenesmus. In a few days the clear 
mucous discharge becomes more opaque, and soon assumes a yellow 
punform look. It is then no longer so acrimonious, and the parts 
become less vividly red, and the inflamed areola less distinctly marked. 
At times the inflammation is so acute and the discharge so acrid, as to 
cause excoriation and ulceration; and cases are related, where adhesion 
of the labia has been the result. The edges of the labia are often 
matted together by the drying of the discharge, and on separating them 
a quantity of shut-up matter flows out. In this way the disease pro- 
gresses, very much resembling the catarrhal affection of the Schneiderian 
membrane, and it properly treated is soon got rid of. Every now and 
then chronic cases of four or five years' standing are seen, the mucous 
membranes becoming thickened and less sensitive, and in these the 
habit of secreting is with difficulty destroyed. The similarity in the 
symptoms of this complaint and gonorrhoea have frequently led to the 
suspicion, that it has been produced by an infectious communication 
from the male sex; and hasty judgments, inculpating innocent indi- 
viduals and destroying the peace of families, have been the result of 
this ignorance The independence and distinction of the two diseases 
is now generally known; and in cases of doubtful character, nothing 
but incontrovertible facts can justify the worst conclusion. 

The early treatment of this inflammation requires the little sufferer to 
be kept in bed, and the vulva to be freely bathed with hot poppy or 
conium fomentations, which ought to be kept to the part by lint soaked 
in the liquor, and covered with oil-silk, so as to preserve the membrane 
constantly moist. When the inflammation has abated, and the dis- 
charge becomes more bland, astringent lotions of sulphate of lime, 
nitrate of silver, or acetate of lead, prove useful. The bowels should be 
kept open, and intestinal worms carefully looked after and if present 
evacuated, and the lost tone of the bowels restored by vegetable or 
mineral tonics. As there is generally a deficiency of constitutional 
power, a nutritious, but not a stimulating diet should be prescribed. 

INFLAMMATION OF THE VULVA IN ADULTS. 

An amount of simple superficial inflammation sufficient to cause much 
suffering, and to produce a free white discharge, attacks the mucous 
membrane of the vulva in adult females. This is rarely referable to 
cold as an immediate cause; and as rarely does it occur as a secondary 
inflammation from irritation in the neighbouring or more distant organs. 
An habitual disregard of cleanliness, and a consequent collection of the 
secretion from the mucous crypts, which after a time becomes solid and 
irritating, may produce it; but more commonly it arises from the in- 
jurious excitement of these parts by masturbation, or as the immediate 
consequence of marriage, or a licentious indulgence in sexual inter- 
course. ° 

There is much pain and heat about the external organs, which, how- 



494 DISEASES OF EXTERNAL ORGANS OF GENERATION. 

ever, are not swollen, but are highly sensitive when the patient walks 
or sits down. The urine scalds when passed; and although there is 
much pruritus present, yet the parts are too tender to allow of their 
being roughly touched. On examination the mucous membrane is seen 
to be uniformly red, and the vagina, for the first half-inch of its extent, 
partakes in the painful sensibility of the vulva. The discharge, which 
is of the white mucous kind, and sometimes more transparent, is diffused 
over the inflamed surface, and is frequently mixed with a leucorrhcea! 
secretion. This form of inflammation does not in any way affect the 
uterus, nor do I believe that diseases of the uterus excite it. 

The inflammation may be so acute, and so deeply involve the 
pudendal structures as to occasion suppuration, which, by extension, 
may include the vulva or lower part of the vagina. But if the case is 
taken in time, and means adopted to lessen the inflammation, abscess 
rarely occurs. The recumbent posture, the sedulous use of poppy 
fomentations, and mild laxatives and salines are the appropriate reme- 
dies. When the inflammation is abated, lotions of the acetate of lead 
or sulphate of zinc are very serviceable, and stop the leucorrhoeal dis- 
charge. The patient must be enjoined to abstain from sexual intercourse 
until the parts are quite restored ; as a too hasty abandonment of this 
restriction has in many cases been followed by a recurrence of the 
acute symptoms. 

ECZEMA OF THE VULVA. 

This affection of the external genitals is characterized by an eruption 
of small vesicles scattered over the mucous lining of the vulva, or the 
adjacent integument of the labia. They soon burst, and their fluid 
mixes with the ordinary vaginal discharge ; or when at the margin of 
the labium, they dry up and scab. Eczema comes on during preg- 
nancy, and constitutes one of the disorders of that state, although wo- 
men are by no means exempt from it who are unimpregnated. It is 
frequently associated with much disorder of the digestive organs, and 
probably the dyspepsia which comes on during pregnancy, from the in- 
dulgence in fancied articles of food, and habitual repletion, may account 
for its prevalence at this time. 

The most prominent symptom in this complaint is the excessive pru- 
ritus and smarting which it occasions. This, indeed, is frightfully ha- 
rassing, and it almost constrains the patient to rub the parts, with the 
hope of temporarily appeasing it. Instead of abating, this only aggra- 
vates the evil, and diffused inflammation with excoriation and ulcera- 
tion, are frequently superinduced. The general health materially suf- 
fers, and the patient becomes weak and hysterical. The parts are so 
very tender and irritable, that the most gentle attempts at separating 
the labia and stretching the mucous membrane, cause severe suffering. 
There is always a great deal of discharge, and the lining membrane is 
seen to have superficial excoriation on it.* 

* An aphthous state of the vulva, extending to the vagina, has been well described 
by Dr. Dewees, as a concomitant of pregnancy. I have seen eczema put on this ap- 



DISEASES OF EXTERNAL ORGANS OF GENERATION. 495 

In treating this local complaint, we must attend carefully to the 
digestive organs, and secure habitual relief from the bowels. An alte- 
rative dose or two of Wue pill, succeeded by some saline medicine, 
will contribute greatly to this end ; and the alkaline carbonates, with 
some mild vegetable tonic, as sarsaparilla, cascarilla, or the compound 
infusion of gentian, will subsequently be of much service. Some of 
the mild dases are readily relieved by the application of a solution of 
nitrate of silver, whilst others require sedatives, both internally and 
locally, before the parts will bear any sueh remedy. Great attention 
to cleanliness is of much importance. In some of the obstinate cases, 
we are called upon to vary the local applications. The black wash 
with opium is sometimes very efficacious, or hydrocyanic acid in water, 
or the acetate of lead in solution. 



PRURIGO OF THE VULVA 

Is a very troublesome affection, attacking females most frequently at 
or about the cessation of the menses. Its characters as a popular dis- 
ease are most faintly marked, and the parts are little altered by it. 
The suffering which is induced from this complaint is most distressing. 
The vulva is the seat of a tormenting irritation, which is increased by 
the warmth of the bed, and the patient instinctively rubs the part, and 
is fit, as she expresses it, to tear herself to pieces. Venereal thoughts 
are often excited from this irritation of the sexual organs, and they 
sometimes become so dominant and imperious as to constitute a form 
of mania. Leucorrhoea comes on, which weakens the vagina, and pel- , 
vie weight and pains are added to the other local symptoms. After a 
time the genitals, especially the labia and nymphse, are somewhat en- 
larged, and the mucous membrane loses its vascular appearance, and 
assumes a white soddened look. I have several times noticed this 
change in the mass and colour of these parts, The general health soon 
suffers ; the constant loss of rest and watchfulness induces much ner- 
vous derangement ; the bowels become irregular ; the appetite impaired ; 
and defective nutrition is seen in the loss of flesh and pallid aspect of 
the patient. 

This disease is sometimes very difficult to remove. It may last for 
months or even years ; sometimes being better, and again becoming 
worse. I have known it come on after labour, and harass the person 
for a length of time in spite of the remedies employed. The local means 
which are indicated for the relief of this complaint, are the various 
kinds of sedatives, some of which have been enumerated in the treat- 
ment of eczema. Tar, or a diluted creosoje ointment, or a tar-water 
hip-bath, may be tried with occasional relief. The patient ought to be 
well apprised of the injury she sustains from rubbing the parts. The 
bowels are to be carefully attended to, and the general health to be 
maintained by a nutritious diet and tonics. Sedatives in the shape of 

pearance when the parts have been inflamed by friction, and I am disposed to ascribe 
the aphthous look of the surface to this cause. 



496 DISEASES OF EXTERNAL ORGANS OF GENERATION. 

hyoscyamus and camphor, &c, and occasional opium suppositories, are 
indicated to allay the local and constitutional irritation. 

It requires to be well remembered, that pruritus of the external ge- 
nitals is associated with other diseases than those of the vulva. It 
belongs in a marked manner to some diseases of the uterus and its ap- 
pendages, and to affections of the urinary bladder and its meatus, and 
frequently is the all-absorbing symptom in the mind of the patient. I 
have on some occasions admitted patients into the ward for some sup- 
posed affection of the vulva, which has turned out to be pruritus from 
disease of the bladder. In these cases we can only hope to cure the 
symptom by diligently seeking out and treating the disease which ori- 
ginates it ; although the local application of sedatives will do much to 
mitigate its severity. 

My attention has been directed by Dr. Oldham to an affection of the 
vulva, which, from its seat, he has denominated, " Follicular Inflam- 
mation of the Vulva." I subjoin his account of it : — 

" The follicles of the mucous membrane of the vulva are both nu- 
merous and large, and I believe them to be the seat of a very intracta- 
ble and most painful disease. It consists of a number of slightly raised, 
highly vascular points, clustering around the elevated border of the 
orifice of the urethra, and skirting the margins of the nymphae. _ It 
does not extend to the labia, or vestibule, or clitoris, and the vagina 
itself is quite free. These points are sometimes isolated and small ; 
but as the disease progresses, several of them coalesce, and here and 
there a minute speck of ulceration may be seen in their centre ; but 
little or no swelling accompanies it. The cases I witnessed, have been 
in married women, of nervous and excitable temperaments, who had 
borne the disease for a long time before the parts were examined and 
its real nature detected. The symptoms are severe, smarting, shoot- 
ing pains in the vulva, which render the sitting posture exceedingly 
painful, and are much increased by walking. Sexual intercourse is at 
first attended with much pain ; but in a short time the dread of it is so 
great as to forbid it altogether. The sphincter vaginas is closely con- 
tracted, and so shuts up the canal, that the leucorrhceal discharge, 
which is always abundant, accumulates in the vagina, and when it does 
escape, flows profusely. On examination, the slightest touch of the 
inflamed points, or the gentlest separation of the parts, makes the pa- 
tient call out with pain. The vagina and uterus do not participate in 
the disease, and menstruation and gestation are not necessarily inter- 
rupted. When once the finger passes beyond the osteum vaginae, no 
further pain is experienced in tracing it along the canal, or feeling or 
balancing the womb ; but a quantity of puriform fluid which had freely 
bathed these parts passes out with the finger, the patients do not com- 
plain of pruritus so much, and there is little fear of friction ; neither 
indeed is micturition painful, although the under edge of the urethra 
is commonly affected. The general health is soon impaired, and the 
patient becomes hysterical, and far less able to endure the local suf- 
ferings." 

It is difficult to assign the cause of this disease, a want of cleanliness 
has not been apparent, nor is it associated with any syphilitic taint. So 



DISEASES OF EXTERNAL ORGANS OF GENERATION. 497 

far as my experience goes, it has not been the physical result of too 
frequent or forcible sexual intercourse, nor in any case has it attacked 
newly married females. In one case it came on a year and a half after 
marriage, when the womb was disordered ; but the uterine affection 
disappeared and pregnancy occurred, although the disease of the vulva 
continued and tormented the person for 5 years. 

The appearance of the affected part is so distinct, that I do not think 
it can well be confounded with the other diseases of the vulva. And 
yet, I suppose Dr. Churchill must have seen it when he speaks of the 
intense pain, equal to cancer of the womb, which he has known to ac- 
company inflammation of the vulva in the adult ; and " a more cir- 
cumscribed inflammation which may attack any portion of the vulva, 
and is often seen merely surrounding the orifice of the urethra, and oc- 
casionally confined to the clitoris." The diffused character of the in- 
flammation is sufficient to distinguish the catarrhal disease from that 
which I am describing, and it differs from eczema in the absence of 
vesicles, and from both in the difficulty of cure. 

I confidently hoped that the application of the nitrate of silver would 
cure this complaint ; but even after a full trial it failed. I destroyed 
the little patches and caused them to slough, and only a short truce 
from pain was the result. In a week or ten days, however, they re- 
appeared, and baffled every effort to destroy them. The use of the 
poppy hip-bath has given temporary relief, by quieting irritation ; but 
neither this nor any opiate has done more than assuage the pain. 
Mercurial washes with opium were attended with like want of success; 
and lotions of acetate of lead or sulphate of zinc varied the remedies, 
but did not effect a cure. Leeches, too, have been applied, and creo- 
sote and tar ointment, but without gaining materially on the disease. 
With these I have given copaiba or olibanum, and have maintained 
the strength and quieted irritation by sarsaparilla, quinine, with the 
tincture of hop and henbane, which have been of service, but have 
not altered the local affection. Such a uniform want of success in- 
duced me to try the effect of a mild mercurial course ; and the result of 
it has been most favourable. I gave the liq. hyd. bichlor. 3J. in the 
compound dec. of sars. with the extract 3 times a-day, and freely 
anointed the parts with an ointment made of two drachms of hydrocyanic 
acid with one of the acetate of lead, well rubbed up in an ounce of 
the cocoa-nut oil. This application has been of great service in most of 
the painful diseases of the vulva, and particularly efficacious in this. 

The irritation and pain of the parts have been greatly relieved by this 
plan, and eventually all traces of inflammation disappeared, and sexual 
intercourse has been resumed without producing suffering. During 
the treatment of this complaint, it is of moment to keep the patient as 
much in the recumbent posture as possible, without absolutely re- 
stricting her to it, and to observe the greatest cleanliness and guard 
against cold. Change of air contributes greatly towards restoring the 
lost strength, and diminishes the constitutional irritability which soon 
appears in the course of the complaint. The following is an illustrative 
case : — 



498 DISEASES OF EXTERNAL ORGANS OF GENERATION. 



Case 107. 

Mrs. B { aet. 28, residing at Hackney Road, consulted me at the desire of 

her medical attendant, for supposed leucorrhoea, for which he had treated her, with 
but partial success, for 18 months. She has been married 9 years, but without preg- 
nancy, and her health was good until 18 months since, when she experienced great 
pain at the vulva, and was much troubled with leucorrhcea. The remedies which 
were prescribed sometimes relieved the pain; but the intermission was of short 
duration, and lately her sufferings much increased. 

1 found the health greatly impaired : the patient was timid, hysterical, and unable 
to endure the least fatigue; her tongue was furred, flabby, and tremulous, and her 
appetite capricious; she had lost flesh, and was in a very desponding state of mind. 
She had dreaded intercourse for some time, and on sitting down she would rest on 
one ischium, and so adjust her seat as to lean only lightly on the affected part. On 
examination I found the inner surface of the nymphse dotted over with several raised 
granulations, with here and there slight specks of ulceration. These were highly 
vascular and exquisitely painful, and when the parts were separated, two or more 
spots would bleed. The sphincter vaginoe was closely contracted ; but the canal 
itself and the uterus were quite free from pain, and a quantity of puriform fluid 
passed away from the vagina, when the finger was withdrawn. 

The treatment of this case extended over a period of 10 months, during which the 
patient from time to time visited me; having allayed the irritation of the parts some- 
what, by keeping her in bed and using narcotic fomentations with saline laxatives. 
I touched the surface with the nitrate of silver, which caused much pain, requiring 
opiates to secure her any rest. Decided relief followed the use of the caustic, which 
induced me to persevere with it for some time; but after a menstrual period the 
disease returned, and little permanent benefit was obtained. Strong nitric acid 
seemed to destroy the diseased spots, and the slough which it caused was attended 
with less suffering than what she ordinarily endured ; but when the sore healed, the 
disease again showed itself. Lotions of sulphate of copper and zinc, oxide of zinc 
with opium, black wash with opium, creosote and tar ointment, and leeches to the 
vulva, were severally had recourse to, but with nothing more than passing benefit. 
Sarsaparilla with iodide of potassium and other vegetable tonics, with sedatives, were 
prescribed to relieve her general weakness. The leucorrhceal discharge was much 
abated by the following medicine from the Guy's Pharmacopoeia, which I have fre- 
quently used with marked advantage : — 

R. Olibani, 3ij. 

Mellis, giij. 

Dec. Cinchon., gv. M. ft. Mist. 
Capiat cochl. ij. amp la ter in die. 

There was not the slightest suspicion in this case of any syphilitic taint ; but I 
determined to place her under a gentle course of mercury, which consisted of a 
drachm of the liq. hyd. bichlo. in the compound dec. of sarsaparilla with the extract, 
twice in the day, and an ointment, of which hydrocyanic acid formed the principal 
ingredient, to be constantly applied to the parts. In three weeks' time the gums 
were slightly touched, and she was much better; the pain was greatly relieved, the 
discharge much abated, and the inflamed follicles less numerous, and far less sensi- 
tive. She went into the country for a month, and reduced the amount of the mer- 
cury to one dose every other day ; and when she returned she was all but well ; the 
vulva was still sensitive ; but notrace of the disease was apparent ; she had indulged 
in sexual intercourse without pain, and had gained flesh and strength. This woman 
menstruated regularly throughout her illness ; but when the caustic was applied, she 
had a coloured discharge from the left nipple, which was turgid and painful, and the 
mammarv gland became irritable. 



DISEASES OF EXTERNAL ORGANS OF GENERATION. 499 



ENLARGEMENT OF THE CLITORIS. 

Before puberty the clitoris is a prominent body, protruding beyond 
the labia, but in the fully developed organs, it is covered and con- 
cealed by these folds of the integument. Sometimes, as a congenital 
defect, it retains and far exceeds its early relation to the other parts of 
the vulva, and appears in the adult as an elongated body ; dispropor- 
tioned to the adjacent structures, and resembling the male sexual organ. 
It is in this state, where the vagina and other female organs are per- 
fect, that hermaphrodism has been supposed to exist. This malforma- 
tion of the clitoris produces few symptoms beyond those of a mechanical 
nature, and these can only be cured by an excision of the over-grown 
organ. 

This part of the vulva, however, is liable to a morbid hypertrophy, 
which is sometimes attended with distressing symptoms. The volume 
which it may attain is enormous ; and cases are recorded where it has 
exceeded in size a full-grown foetal head. I have never seen it so 
large as this, but in my own observation, it has appeared as a length- 
ened growth, varying from 1 to 3 or 4 inches in extent, and sometimes 
bulging and spreading out at its free extremity. 

As erectile tissue enters largely into the structure of the clitoris, and 
the cavernous bodies are distended during venereal excitement ; it has 
been imagined that frequent sexual indulgence has been the common 
exciting cause of the hypertrophy. My own observation leads me to 
regard an abandoned life, or what is perhaps a still more pernicious ex- 
citant, a secret self-pollution, as an occasional cause of this organic 
disease. But the researches of Parent Duchatelet, and the observations 
which I have been enabled to make at Guy's Hospital, prove that 
there is no necessary connexion between an habitual sexual indulgence, 
and the permanent increase of the clitoris. Out of 6,000 registered 
prostitutes in Paris, only three were affected with this disease ; and I 
have often been struck With the integrity of the external genitals in 
prostitutes, while the uterus and ovaries have been bound in all direc- 
tions by bands of false membrane. It is the internal organs of genera- 
tion which receive the impression, and become the seat of morbid 
changes, resulting from licentious habits; although physiologically 
speaking, the clitoris is regarded as the seat of the pleasurable feelings 
which spring from sexual coitus.' 

The symptoms which attend this affection are by no means uniform. 
In some instances the mucous membrane becomes so dry and indurated, 
so much, in fact, like ordinary skin, that the friction it is subjected to 
has no prejudicial effect, and does not produce pain or excitement. 
The practitioner is consulted about it from the feeling, that the forma- 
tion is irregular or unnatural, or from a hinderance to sexual inter- 
course : and perhaps, too, from some slight mechanical impediment to 
free and unrestrained movement. When, however, these insensible 
enlargements have reached a greater magnitude, they are apt to exco- 
riate and ulcerate on their lower surface, which causes much local 
irritation, and if neglected, may injure the general health. 



500 DISEASES OF EXTERNAL ORGANS OF GENERATION. 

Sometimes an enlarged clitoris is marked by exquisite sensibility of 
its mucous surface. This occurs usually in women of an irritable, ex- 
citable temperament, and may attack young females soon after puberty, 
or at any later period of life. The effect of this morbid sensibility is 
felt beyond the local pain which it produces. It frequently gives rise 
to sexual passion, and subdues every feeling of modesty and delicacy. 
I have been consulted about young females who have become the sub- 
jects of these tormenting emotions, always aggravated by digitation. 
The consequence of this physical attempt to assuage the local irritation, 
has been to inflame and ulcerate the part, causing also a copious leu- 
corrhceal discharge, with painful and irregular menstruation. The 
health soon becomes impaired, constant headache, referred particularly 
to the occiput, is present ; and there are sometimes frequent attacks of 
hysteria. The mind loses all discipline, and the thoughts and expres- 
sions assume a sentimental and amatory character, while compassion 
and pity are sought to be elicited from the attendants. This train of 
symptoms, which may extend to a genuine nymphomania, appears to 
originate exclusively from an excited, enlarged, and sensitive clitoris. 

In the treatment of this affection, we must be guided by the attend- 
ant symptoms. If the growth is insensible, and relief is sought from its 
mechanical annoyance, or if it put on an unhealthy ulceration, the best 
way is to excise it ; for we cannot hope to obtain absorption, or sen- 
sible diminution of its size, by any medicinal means. Excision also is 
required when the growth is attended with undue sensibility ; but in 
cases where the clitoris is not very large, we may probably succeed in 
arresting its further growth, and relieve the distressing feelings of the 
patient, by keeping her at rest on a mattress, and applying cool satur- 
nine lotions. A few leeches may be applied near the part, if inflam- 
mation has been excited, and pencilling it with a solution of nitrate of 
silver, every two or three days, is a valuable topical measure. Hydro- 
cyanic acid in solution, will be found very efficacious as a lotion. The 
health must be supported by mild vegetable tonics with mineral acid, 
and a nutritious but unstimulating diet. A cold shower-bath every 
morning, or every other morning, will relieve the headache, and is an 
excellent hygienic auxiliary. 

Hard fungating growths are sometimes seen springing from the cli- 
toris ; and warty excrescences will spread from the vestibule and involve 
the prepuce of the clitoris. It is also the occasional seat of malignant 
disease, which runs its course as in other parts, and may infect the 
neighbouring inguinal glands and destroy, by a more extensive propa- 
gation to the lumbar glands and other abdominal structures. I have 
never known excision of a clitoris affected with malignant disease, do 
more than suspend the cancer, which has speedily re-appeared in the 
original or adjacent parts. 



DISEASES OF EXTERNAL ORGANS OF GENERATION. 501 



VASCULAR TUMOUR OF THE MEATUS UR1NARIUS. 

This is by no means an unfrequent affection of the mucous membrane 
of the urethra. It usually attacks the young, whether married or single ; 
and very rarely is seen after the cessation of the menses, when the 
urethro-sexual passages are less subject to vascular turgescence. It 
consists of a small granular tumour, generally pediculated and mova- 
ble, attached to one part of the margin of the meatus urinarius or just 
within the urethra, whose two prominent characteristics are great vas- 
cularity and exquisite sensibility. Sometimes these growths are not 
movable but appear like several raised coalesced granulations, or oc- 
casionally two or more isolated and independent ones may be seen near 
together. Every now and then they extend partially along the urethra, 
and may even be located at the neck of the bladder. They are covered 
by a delicate, pale membrane, which is broken on being touched during 
examination, and blood exudes from the soft, feeble, and injected ca- 
pillaries. The symptoms which attend the growth of these vascular 
bodies, mainly arise from their great tenderness, and the suffering 
occasioned by their being touched, or in any way interfered with. 
Thus, if they interceptor come in contact with the stream of urine, 
the act of passing water causes intense suffering ; and this is usually 
the first and most common symptom of the complaint. After a time 
the urethra and bladder become irritable, and the frequent desire to 
micturate is suppressed by the dread of the pain which it excites. 
Sexual intercourse is intensely painful, and is therefore obliged to be 
suspended. Walking exercise is attended with suffering, and in fact 
any movement of the vulva, by slightly displacing or pressing upon the 
growth, produces instant pain. Leucorrhcea accompanies this affection, 
and is sometimes profuse. There is much weight about the pelvis, 
with lumbar pain, and pains in the upper part of the thighs ; and the 
vulva itself is the seat of much uneasiness and irritation? There can 
be no difficulty in recognising this complaint when once an examina- 
tion is permitted, which is generally willingly granted. 

The main trouble we encounter in the treatment of these tumours, is 
their tendency to re-appear. If they are snipped off with scissors, and 
the part allowed spontaneously to heal, there is every probability that 
it will repullulate and cause the same symptoms. If these growths are 
not movable, and attached by a pedicle, I have found that the diligent 
application of nitrate of silver, freely applied over and around them, will 
eventually get rid of them ; but the process of destruction is tedious and 
attended with great agony. It is generally, indeed, necessary to apply 
opium to the part after the application, and to soothe the patient by some 
morphia or extract of hyoscyamus at night. If, however, they can be 
easilyreached,theyshouldbedrawn out from the meatus, so as thoroughly 
to expose their attachment, and then removed by a pair of curved scis- 
sors ; detaching at the same time, the mucous membrane to which they 
are affixed. After this the excised part should be touched with nitrate 



502 DISEASES OF EXTERNAL ORGANS OF GENERATION. 

of silver, which should be repeated occasionally until the wound heals. 
I greatly prefer this plan of treatment to the application of a ligature, 
which is attended with more pain and irritation, and needs the same 
subsequent attention. Should the deeper parts of the urethra be affected, 
a bougie must be passed, smeared over with extract of belladonna, or 
with an instrument nicely contrived for the purpose ; nitrate of silver 
may be efficiently applied. 



THICKENING OF THE CELLULAR MEMBRANE SURROUNDING THE 

URETHRA. 

This affection of the urethra was first described by Sir C. Clarke, 
and consists essentially of an inflammatory hardening and thickening of 
the cellular structure, with a corresponding increase in the erectile tis- 
sue of the part. The veins particularly become varicose and distended, 
when the patient walks about or stands for any time. It occurs in 
women who have had large families, and the cause of its production is 
the vascular turgescence of the urethra and sexual canal, and the pres- 
sure to which both are subject during gestation and protracted labour. 
On examination, an enlargement is distinguished behind the pubes, and 
the entire urethra may occasionally be felt fuller and more than usually 
distended. If the patient be made to bear down freely, and the labia 
be separated, a portion of the urethra is seen, raised and tumid, of a 
dark-red, or even livid colour, from the great increase of the vascular 
tissue. These blood-vessels contribute materially to the hypertrophy 
of the part, which may be sensibly lessened on pressure being applied, 
and the blood directed into other channels. 

This disease is sometimes of a comparatively trifling character, the 
attendant symptoms being slight, and borne without complaint by the 
patient. A sense of weight and discomfort about the part, increased 
on walking or standing, with an endurable amount of pain in sexual 
intercourse and micturition, may be all the annoyance which is expe- 
rienced. But this applies only to a mild form of the complaint, such 
as may be seen after labour, and forming one amongst the lesser 
troubles which protract the getting up, but which may eventually dis- 
appear under rest and astringent lotions. In the worse and more com- 
mon form of this disease, there is much harassing suffering. The lining 
membrane of the urethra becomes painful, and its softened tissue may 
be excoriated, leaving an irritable surface. The canal itself is some- 
times interrupted by the formation of a pouch in its posterior wall, in 
which a small quantity of urine remains, keeping up much local irrita- 
tion. I have sometimes seen small abscesses form in the thickened 
tissue beneath the mucous membrane, whieh had given way, causing 
severe suffering. The general health is impaired from the broken rest 
which is thus induced ; and the mucous membrane of the vulva and 
vagina participate in the irritation, and give out a copious leucorrhceal 
discharge. In one case which was lately under my care, the suffering, 



DISEASES OF EXTERNAL ORGANS OF GENERATION. 503 

which was severe, mainly arose from pruritus and smarting of the vulva. 
In this case a pouch, which held about two or three drachms of urine, 
was felt protruding the whole of the vagina, from which place it was 
readily emptied by pressure. 

In order to relieve this condition of the urethra, it is necessary to 
keep down the tumid blood-vessels, which may be effected by emptying 
them of blood by opening or leeching them, and afterwards applying 
some astringent lotion to reduce their morbid size. This is best effected 
by a solution of the nitrate of silver, which is often alone sufficient to 
cure the complaint. The horizontal posture is necessary, as the veins 
quickly distend when the patient walks or stands, the catheter must be 
passed occasionally, and the urethral pouch kept empty. If the suffer- 
ing occasions much watchfulness,, and the constitutional symptoms in- 
crease, it will be necessary to give sedatives to procure sleep ; and 
mild tonics, as the citrate of quinine and iron, the impaired strength : 
sexual intercourse should be suspended. The hypertrophied tissue may 
also be reduced by means of bougies, or, as Sir Charles Clarke advises, 
by the application of a piece of wax candle or a roll of linen well wetted 
with some astringent solution, as of alum, or the diacetate of lead, or 
the sulphate of zinc. 



DISEASES OF THE VAGINA— PROLAPSE OF THE WALLS OF 

THE VAGINA. 

The vagina, as a copulative organ, and in its relation to the uterus 
as an efferent duct, is obnoxious to many different diseases. In com- 
mon with the structures placed within the vulva, it is sometimes affected 
with erythematous inflammation, and is the common source of leucor- 
rhoea. Warty growths may vegetate within it ; its veins may be en- 
larged into varices ; and one or more of its mucous follicles may be 
filled out into a fluctuating encysted tumour, closely allied in its mode 
of formation to the encysted tumours of the labium, or the sebaceous 
cysts in the skin. Polypoid growths spring from its sub-mucous tissue, 
carrying the lining membrane before them, and either partially or en- 
tirely block up the passage, or protrude beyond the osteum and resemble 
in their size, appearance, and situation, the procident womb. A case 
of this kind was lately under my care in the Hospital, in which a growth 
the size of a large hen's-egg, covered by the rose-coloured mucous 
membrane, had passed the orifice of the vagina, and had been mistaken 
for the protruded uterus. The lower surface of this growth had a large 
circle of ulceration very similar in its direction and aspect to that which 
takes place around the os uteri when the womb has been unreduced 
for any length of time. A careful examination soon detected the ab- 
sence of the os uteri, and the womb was felt in its proper situation. 
The growth was excised by Mr. Key, and the patient quickly recovered. 
These tumours do not bleed, being composed of cellular tissue and 



504 DISEASES OF EXTERNAL ORGANS OF GENERATION. 

fat, and a few blood-vessels ; but their vascularity is by no means 
striking. 

Congenital defects and malformations of the vagina are not unfre- 
quently met with. Its orifice may be entirely closed, not only by an 
imperforate hymen, but also by a curtain of the common integument. 
The canal may be too short, terminating abruptly in a cul-de-sac ; or 
a congenital stricture may be formed, retaining the menses, which col- 
lect behind and dilate the lower part of the uterus.* A perfect septum 
may exist, showing the original quality of the duct, which in some rare 
instances may coincide with a double uterus and two mouths, a perfect 
specimen of which deformity is in Dr. Oldham's possession. The 
occurrence of fistulous communications between the vagina and the 
rectum and bladder, may exist as malformations, or be induced from the 
separation of a slough after a protracted or instrumental labour. Adhe- 
sive inflammation sometimes follows a like physical injury to this part, 
which may partially or almost entirely obliterate the canal, leaving only 
a small sinuous channel through which the menses make their way, 
and through which, unfortunately, the semen may be transmitted and 
impregnation ensue. 

The anatomical relations which the vagina bears to the urethra and 
base of the bladder in front, and the rectum behind, expose its walls to 
be displaced and even everted, from the mechanical encroachment of 
either the one or other of these adjacent organs. An entire eversion of 
the vagina is usually associated with a procident state of the womb, of 
which it is but a secondary effect. In the same way, only as a far more 
rare and accidental occurrence, either one or other wail of the vagina, 
the posterior one more frequently, may be carried forward, and even 
partially prolapsed by the increase of any growth which is placed be- 
tween it and the adjoining organ. Thus an abscess, or encysted or 
hydatid tumour, may directly produce a slight prolapse of the vagina. 
But, independently of these causes, we find the vagina protruding be- 
yond the vulva, and forming a large swelling, in the formation of which 
either the anterior or posterior wall, or even the entire cylinder, may 
be involved. For the production of this affection, the vaginal parietes 
must be in a relaxed and yielding state, which is usually brought about 
by habitual leucorrhoea, or in women of loose fibre with large pelves, 
who have borne many children. In persons so circumscribed, an ac- 
cumulation of urine in the bladder, or of fasces in the rectum, is suffi- 
cient to distend the nearest wall of the vagina, which readily yields 
before it; and, after a repetition of this process, the swelling bulges 
out, and the mucous membrane of the vagina is exposed. The volume 
and physical character of the swelling differs according as the contents 
of the rectum or the bladder compose its bulk. If the bladder has pro- 
truded the wall, forming a vaginal cystocele, the swelling is globular 
and elastic, and imparts, on handling, the sensation of its fluid contents. 
On examining it, the mucous membrane of the vagina is seen of its 
own rose colour, or sometimes livid from venous congestion, and de- 

* Vide Rusher's case, with a drawing in Guy's Reports, vol. 2d, p. 244. 



DISEASES OF EXTERNAL ORGANS OF GENERATION. 505 

prived of its ribbings from distention. No aperture can be detected in 
its lower surface, and the finger can readily enter behind it, the very 
effort at examination partially reducing it, and the uterus may be felt 
up above ; then will the fact, that catheterism materially reduces the 
swelling, sufficiently characterize the complaint, and distinguish it from 
procidentia uteri, with which it is sometimes confounded. If the tu- 
mour be formed by the distended rectum displacing the posterior wall, 
the swelling is less voluminous than in the preceding variety, and more, 
hard and unimpressible. On examination, the contained scybalaB may 
generally be felt, and the finger may be passed up the vagina before it, 
where the uterus is found to retain its proper position. This affection 
is called vaginal rectocele, and is always associated with a torpid state 
of the lower bowel, and its impaction with faeces, which have become 
hard from the absorption of their fluid part. 

The descent of a circular fold of the vagina is rarely seen, and it is 
difficult to account for its production. A preparation showing it is in 
the Museum of Guy's Hospital, where the vagina has several ulcerations 
on its surface. This is not a painful complaint, but it produces much 
mechanical inconvenience. It is attended with pelvic weight, and a 
feeling of dragging at the umbilicus, with a sense of fulness and dis- 
tention about the rectum. Fatigue is quickly experienced in walking, 
and frequently dyspeptic symptoms are associated with the faulty state 
of the lower bowel. A mucous discharge is generally present. The 
bladder is not easily emptied ; the muscular contraction acts at a dis- 
advantage ; and the patient instinctively seeks support to the distended 
base of it, by pressing it herself. Sexual intercourse is more or less 
impeded, according to the size and variety of the descent, the difficulty 
being necessarily worse when a cylindrical fold is prolapsed. 

The main object to be kept in view in treating this disease, is to 
restore the lost tone of the muscular structure of the vagina, so as to 
enable it to bear up against pressure from the contiguous organs ; and 
this is to be primarily accomplished by preventing this pressure. The 
bladder must continually be kept empty ; for which purpose the catheter 
must be occasionally passed, and the patient directed to avoid the ac- 
cumulation of urine ; or, on the other hand, the rectum must be freely 
washed out by enemata of castor oil, and the bowels evacuated daily 
without straining. These injunctions, with rest, will contribute greatly 
to the patient's comfort and improvement. The vagina ought twice a- 
day to be injected with some astringent lotion, such, as alum or oak- 
bark, and a cold hip-bath is a useful expedient. Should these means 
fail to impart the requisite tone to the vagina, its parietes must be sup- 
ported by some mechanical means. An elongated pessary, slightly 
curved, of the ordinary length and mould of the vagina, formed of 
caoutchouc, is the best instrument for the purpose. The pessaries 
which are adapted to support the womb are not fitted for this disease, 
as they do not embrace a sufficient extent of the yielding tissue of the 
vagina. A cheap and a very good pessary is formed from a roll of 
linen covered with oil-silk, which I have found answer the purpose 
well. It has been proposed t© dissect off a strip or triangular portion 



506 DISEASES OF EXTERNAL ORGANS OF GENERATION. 

of the mucous membrane, and to bring the edges together, so as to 
diminish the size of the canal, and enable it to sustain, without ever- 
sion, the pressure to which it is subjected. The same effect would be 
produced by cauterizing portions of the vaginal canal, which would 
effectually contract its dimensions. I am not in the habit of adopting 
these measures ; but they undoubtedly increase our resources in the 
treatment of this affection. 



APPENDIX. 



APPENDIX. 



ON THE MORBID CONSEQUENCES OF UNDUE LACTATION. 

I add this essay and cases by way of an appendix, not on account 
of any intrinsic worth ; but from a belief that the opinions and facts 
stated in them, may lead to a watchful and scrutinizing diagnosis of the 
important class of cases referred to, which certainly bear a close relation 
to the object of the present work. 



Undue lactation, as a matter of medical inquiry, has not arrested the 
attention of the profession so much as its importance demands. Its in- 
jurious consequences are so frequently overlooked, or, being misunder- 
stood, are attributed to other causes, that it cannot be regarded as un- 
profitable to comprise, in a few observations, the history and treatment 
of this affection, in its mild, severe, and complicated forms. The sub- 
ject is practical and interesting; and avoiding controversial views, no 
opinions will be advanced which are not supported by cases con- 
stantly occurring. 

Little has hitherto been written on undue lactation; Dr. Marshall Hall, 
so far as I know, being the only author who has bestowed upon it more 
than a few incidental remarks. The essay of this able physician is a 
valuable contribution to our knowledge of this disease ; although even 
Dr. Hall has scarcely done more than allude to the severer functional 
derangements, and the still more dangerous lesions of the brain and 
lungs. 

Without hesitation I may then observe, that exhaustion — generally 
attended by symptoms of reaction, but occasionally by depression so 
extreme as almost to conceal any such effort — constitutes the prominent, 
the essential feature when lactation has become a disease. Anaemia, 
with irritability and universal pallor, are as apparent as in chlorosis— of 
course in different degrees. In some instances there is distressing de- 
bility ; in others, and less serious cases, there is only trifling anaemia, 
and proportionately slight pallor. Local congestion, also, as it is the 
result of an irregular distribution of the blood, may partially modify the 
anaemia and pallor, by producing, in certain organs, a temporary but mor- 
bid energy, and, by fulness of the capillaries, a less pallid and unhealthy 



510 APPENDIX. 

aspect of the surface. Still, exhaustion is the permanent morbid state 
associated with undue suckling. 

Were the morbid consequences of this disease invariably functional 
and slight, even then, as occurring frequently, it would deserve atten- 
tion ; but, when it is remembered, that not only severe and complicated 
functional affections, but occasionally lesions even of an organic and in- 
curable kind, may be traced to its influence when misunderstood or im- 
perfectly treated, it certainly deserves especial attention. It may, I 

think, be proved — 

First, That lactation, to be morbid, need not be protracted : evil con- 
sequences may ensue soon after its commencement; occasionally, with- 
in a few weeks ; more frequently within a period prolonged beyond nine 

months. 

Secondly, That organic lesions may, although very rarely, result irom 

undue suckling. 

And, Thirdly, That weaning the child, is indispensable to the cure, 
without which all other remedies will be inefficient. 

It will be unnecessary to dwell largely on the history and symptoms 
of undue lactation: a few remarks will suffice to place the subject in a 
clear light. The period of suckling is happily, in the majority of wo- 
men, one of health and enjoyment; still, the exceptions to this rule 
are by no means few : nor can it be expected, in an artificial and in- 
creasingly luxurious state of society, that the number will diminish. 
We do not find that robust and plethoric women often suffer from over- 
nursing. If occasionally this be the case, the lactation has probably 
been protracted to fifteen, eighteen, or twenty months, or even to a 
longer term ; and it certainly cannot be a matter of surprise, if then, as 
the consequence of such imprudence, irritability, exhaustion, and va- 
rious painful affections, shall occur. Women, originally of susceptible, 
weakly, and especially of strumuous constitutions, whose minds have 
early and long been cultivated at the expense of their physical strength, 
who live in confined and unhealthy places, who, before marriage, have 
suffered from chlorosis, and who have since been weakened by hemor- 
rhagic and leucorrhceal discharges, or indeed by any undue secretion, 
are most frequently the sufferers from prolonged suckling. Such mo- 
thers can scarcely nurse at all ; and others, somewhat stronger, having 
begun lactation favourably— by a poor and restricted diet ; by nursing 
entirely, without the aid of feeding the child artificially; by broken 
rest; by anxiety; and by other circumstances too numerous to detail — 
quickly become exhausted, and present the whole series of symptoms 
constituting the malady of over-lactation. 

Occasionally, in a few weeks— commonly in a few months — it will 
be apparent, from the imperfect nourishment of the infant, and from the 
debility, anaemia, and pallor of the mother, that the injurious conse- 
quences of over-nursing have commenced. Amongst the earlier symp- 
toms of failure, are a heavy, dragging sensation in the back and loins, 
and directly between the scapulae, when the child is at the breast ; and 
a feeling of peculiar sinking and emptiness at the pit of the stomach, 
and over the whole abdomen, for hours afterwards. On strict inquiry 
it will be discovered, what is often anxiously concealed, that the milk 



APPENDIX. 



511 



is scanty in quantity, and with difficulty secreted; and that without 
long intervals, scarcely any fresh supply would be furnished. At this 
point, much might be done. If weaning were at once adopted the 
symptoms would soon disappear; or if only partially adopted (by the 
child being judiciously fed, and the mother's rest at night secured in- 
stead of being continually broken), lactation might be safely continued- 
as the appetite, digestive powers, and strength of the parent would be 
thereby improved. But the attempt to nurse is often persevered in 
without these advantages; and the morbid results are soon aggravated 
Besides an excitement or depression of mind, there is proneness to 
hysteria; the pulse is quicker than natural, and easily compressed- the 
muscular system is weakened ; the appetite is nearly destroyed, or at 
least fastidious and unhealthy; the bowels are either constipated and 
natujent, or painfully griped and slightly purged ; there is headache or 
giddiness, with impaired vision ; pain between the shoulders, or in the 
sides, below the cartilages of the false ribs; and, if the suckling be 
continued, there is a swelling of the ankles, oedema of the face, and fre- 
quent palpitation. Such are the symptoms commonly attendant, even 
on a recent case; and it is only requisite that their intensity should be 
increased, and they will then correctly portray a severe and protracted 
example of undue lactation. Nor is it at all uncommon that one or 
several of these symptoms shall exist in marked prominence, so as to 
excite the peculiar apprehension of the patient, and the almost exclu- 
sive attention ot the practitioner. Impaired appetite is a marked at- 
tenoant of this malady, and palpitation is also common. A chlorotic 
aspect, and slight emaciation, often give the first alarm; and dimness 
ot vision, exciting fears of amaurosis, seldom fails to induce anxiety 
lne contrast of such a case, with one of favourable suckling, where 
health, cheerfulness, and vigour are enjoyed for many months, must fix 
the attention of the practitioner on the disease. 

Let it be remembered, that the morbid process now sketched is en- 
tirely functional: at least, there is no symptom in the series which may 
not have a functional origin, and be confined within the limits of func- 
tional disease. 



Before leaving this part of the subject, it will be proper to allude to 
some of the complications of morbid lactation, giving the priority to pro- 
fuse menstruation, menorrhagia, and leucorrhoea. That the function of 
the uterus should be sooner or later disturbed by the continuance of a 
disease originating in an organ intimately connected with its own eco- 
nomy, might, from analogy, be easily inferred ; more especially when 
the malady had deranged the whole system, on the health and activity 
of wmch the uterus is so greatly dependent. Thus, after the evils of 
over-lactation, already described, are fully realized, the uterine mucous 
lining, as well as its muscular tissue, partake of the general debility ; 
and not only is there profuse menstruation, but from Relaxation of its 
capillaries, permits the escape of large quantities of blood: add to these 



512 APPENDIX. 

losses, the almost constant drain of leucorrhoeal discharge, and it will 
then be understood that over-lactation, thus complicated, may seriously 
and alarmingly exhaust a delicate and irritable female. How far such 
a condition may prepare the way for organic change of the womb, is 
not easily determined. From observation, I am disposed to think it 
favours abrasion, ulceration, and vivacious growths. 

Functional Amaurosis, accompanied by congestion of the conjunctiva, 
is a frequent result of excessive lactation, and seldom fails, from its inter- 
ference with the sight, to arouse the patient's fears lest vision should 
be entirely and permanently lost. These apprehensions may easily be 
allayed; as, doubtless in the greater number of cases, prompt weaning 
will alone remove the affection; still, it may be necessary repeatedly to 
apply small blisters near the eye, and absolutely to forbid its employ- 
ment. Improved diet, country and sea air, exercise out of doors, iron 
and quinine, are important remedial auxiliaries. Nor is it unimportant 
that quickly-returning pregnancy should, if possible, be avoided. I 
have known several instances where, during a pregnancy immediately 
succeeding the exhaustion from over-nursing, the eye has been almost 
constantly in a state of " blood-shot" or congestion, and the sight ex- 
cessively imperfect. Months, and even years, sometimes elapse, where 
able treatment has done its best before distinct and strong vision is re- 
acquired. Specks, and slight ulcerations of the cornea, are occasionally 
connected with the exhaustion and irritability of nursing. In all these 
cases, provided there be no serious organic change, the sufferer may be 
encouraged to expect the restoration of this most invaluable faculty. 

Several examples of jactitation have fallen under my notice. In one 
poor woman, an out-patient of Guy's Hospital, the seizures always 
occurred after she had nursed for three or four months ; and they were 
so violent, that she was compelled to lay down her baby when they 
occurred, lest she should let it fall. In another young and hysterical 
patient, who had borne children very quickly, there w T as, during lacta- 
tion, a continual and slight twitching, almost universal throughout the 
extremities, but especially of the face. In both, weaning was neces- 
sary before the sixth month, more on account of leucorrhcea and general 
irritability, than for the jactitation. 

Epilepsy has been noticed by authors as the product of over-suckling, 
on the same ground as inanition ; losses of blood, and deficiencies in 
its quantity and quality, are known pathologically to be productive 
of this malady; and I could adduce several instances where fits, diffi- 
cult to be distinguished from decisive and unquestionable epilepsy, 
have occurred. 

Insanity, more or less permanent, may originate from over-lactation, 
commencing by peculiarity of sentiment or temper, and plainly evinced 
by pertinacious adherence to an opinion once formed, however erro- 
neous; and scarcely at all more strikingly displayed than in a deter- 
mined opposition to any advice having for its end an entire or even a 
partial weaning. In this early stage, the further advance or the pro-, 
tracted continuance of the malady might be prevented ; but, instead of 
weaning, larger quantities of porter or wine, with animal food, are most 
improperly resorted to. Still the desired supply is not obtained. The 



APPENDIX. 513 

stomach, being weakened, is scarcely able to bear a diminished diet ; 
fever and indigestion, apparent and temporary, not real strength, are 
the unavoidable consequences of this increased supply. Together with 
a continued sparing secretion of milk, the symptoms already described 
are aggravated. The insanity becomes positive and acute, the pulse 
quick and sharp, the skin parched, and the whole system deranged. 
The condition of the patient is no longer doubtful ; her actions are often 
violent; and, without personal restraint, serious, perhaps fatal injury 
might be inflicted on herself and those around her. I agree, however 
with Dr. Locock, that the aberration of undue suckling is rarely of this 
serious kind, excepting where generous diet and wine are injudiciously 
administered ; more commonly it shows itself in weakness and absurd 
ideas, in whim and caprice. In this stage, if weaning and careful 
treatment be adopted, the symptoms often subside easily and quickly ; 
while in other cases, where probably a disposition to insanity exists 
hereditarily, the disease is of longer duration, requiring seclusion and 
confinement for its cure. If it be asked whether permanent insanity is 
ever the result of the aberration of undue suckling, I confess that I am 
unable to answer the question. In my own practice, such has never 
been its consequence ; nor, so far as I know, have I discovered an ex- 
ample of the kind. The exhaustion of over-nursing induced the reac- 
tion and irritability on which the malady depends ; and as this is gra- 
dually removed, by the formation of a larger quantity of better blood, 
the insanity passes away, and the individual slowly recovers her lost 
reason. It may perhaps be said, by those who regard this malady less 
seriously, that the insanity would have occurred independently of its 
intervention. The appended cases negative such an opinion. Addi- 
tional confirmation is also furnished by the result of protracted lactation 
after another confinement. If, after such an event, more especially if 
the interval between the deliveries has been short, and the suckling be 
again protracted, a similar aberration will probably ensue, indicating 
the propriety of greatly curtailing the time of lactation, if not of entirely 
giving it up. 

It is not difficult to show many points of resemblance between this 
form of insanity and puerperal mania. The latter most commonly oc- 
curs in women of weakly, hysterical, and irritable habits ; and in the 
same class, over-lactation is most frequently witnessed. In the greater 
number of examples of puerperal insanity, a modified antiphlogistic 
treatment only, comprising small local bleeding, cordial aperients, and 
particularly sedatives, with mild nourishment and tonics, is most suc- 
cessful ; and the same may be said of the insanity from over-lactation., 
Puerperal aberration is rarely permanent, if insanity be not hereditary" 
and if improper treatment has been avoided. The same observations 
are true of the insanity of over-lactation. The former is disposed to 
recur in after-confinements ; and the latter will show itself afresh, after 
successive and injudiciously protracted nursings. There is, however, 
a marked difference in the frequency of the two diseases. The shock 
of parturition, the suddenness of the transition from pregnancy to the 
puerperal state, and the establishment of lactation itself, all of which 



514 APPENDIX. 

involve considerable changes in the circulation and in the nervous sys- 
tem, sufficiently account for the prevalence of the one malady over the 
other. 

The pathology of these functional results of undue suckling is by no 
means intricate or doubtful. An impaired and attenuated condition of 
the blood, and a consequently depressed state of the nervous system, 
especially of the organic system of nerves, is the clue by which all the 
symptoms may be unravelled. 

I pass on now to notice what my experience leads me to believe to 
be a fact: viz., that very prolonged undue suckling may, although rarely, 
induce organic change in the brain, lungs, and uterus. 

It has already been remarked, that headache is a frequent concomitant 
of the malady : nor can the practitioner be too strongly impressed with 
the hazard arising from its constancy. So long as it is general, not 
very severe, and transient — so long as it does not recur periodically 
with marked premonitory symptoms — it may be viewed as compara- 
tively free from risk. But if it be dreaded, on account of the perma- 
nent uneasiness which it has already produced, or from its intensity 
and acuteness ; if it seize on one part of the head, and remain fixed 
there ; if its paroxysm be preceded by rigours, and if the pain never en- 
tirely subsides ; more especially, if there be partial paralysis, mental 
peculiarity, or forgetfulness approaching to imbecility, or any other 
anomalous symptom indicative of deranged nervous action; for instance, 
an unusual affection of the eye, such as double or impaired vision, or 
of the auditory nerve, injuring the hearing, or rendering it excessively 
and painfully acute ; or if there be impeded deglutition ; then danger 
exists, and a softened, or otherwise structurally altered condition of the 
brain may be feared. If weaning has not been adopted, it ought now 
to be urgently enjoined. 

Again, the lungs may become organically affected ; or, to express what 
is probably more strictly accordant with the fact, a tendency to phthisis, 
hitherto latent, may be developed ; tubercles, till this period quiet and 
inactive, may soften, and all the symptoms of consumption may super- 
vene. A slight and occasional cough need not excite apprehension ; 
but if it be short, hacking, and habitual ; if the breathing be quick, and 
disturbed on slight occasions ; if there be fixed pain in the side, or 
over any part of the thoracic region ; and if, added to these symptoms, 
there be progressive emaciation, even doubtful sputa, morning perspi- 
ration, and a constantly quick pulse, it may be confidently assumed, 
that if serious mischief has not already occurred, it is at hand. The 
stethoscope will scarcely fail to reveal some important structural lesion. 

The uterus may also undergo organic change, as the result of undue 
suckling. 

The. pathology of these structural lesions need' not occupy us long. 
In reference to the lung, there can exist no doubt that undue lactation 
is favourable to the development of phthisis ; and that if the supply of 
milk in women of this class did not generally very soon cease, many 
more would fall victims to protracted nursing. 

As to the brain and uterus, we are so much accustomed to see their 
organic changes following a state of hyperemia and repeated irritation 



APPENDIX. 515 

and inflammation, that we are indisposed to recognise such conse- 
quences from a state where exhaustion is the prominent feature ; and 
yet this is physiologically correct. It is universally admitted, that the 
blood nourishes the solid structures of the body; and without its health- 
ful influence their organization cannot be supported. If then, by an 
undue and protracted lacteal secretion, the quality as well as the quan- 
tity of the blood is impaired, it seems an inevitable result, that a morbid 
modification of the firm and solid organs of the body must ensue. Just 
in proportion as the fibrin and albumen of the blood are drawn off, must 
the structures alluded to suffer in their organization. And, as indu- 
ration results from inflammation, where there is generally, at least very 
often, an undue proportion of fibrin, so may softening of the brain and 
uterus, without malignancy, follow in the course of undue suckling, 
independently of any inflammatory action. Andral supports this 
opinion. He says : — " Where shall we find the symptoms of encepha- 
litis, carditis, hepatitis, nephritis, metritis, &c, in various cases of soften- 
ing of the brain (especially of its white central portion), and of the 
heart, liver, kidneys, uterus, &c. ; every one of which may pass into 
such a state of softening, that its tissue may be torn or broken down 
into a pultaceous mass, without having given rise to a single symptom 
which could lead to a suspicion of the existence of inflammation." 

Treatment. — The indications in the merely functional affections are 
not difficult to meet. Where the symptoms of exhaustion are slight, a 
better diet, a careful regulation of the bowels, a tonic treatment, and, 
above all, diminished suckling, will often avail. Nor is it necessary to 
urge very strongly, because their propriety is evident, that the child 
should be fed two or three times within the twenty-four hours, and that 
unbroken sleep during the night should be secured to the mother. But 
let it be remembered, that this will not always prove successful. A 
continuance of the debility, or the aggravated prevalence of one or more 
of the symptoms already enumerated, will plainly indicate the necessity 
of immediate and entire weaning. If the child be purged, or become 
gradually emaciated, it will corroborate the importance of this step. 

Where organic disease is threatened, especial attention must be paid 
to the organ in which it seems likely to occur. Cupping, or leeches, 
may be required ; and counter-irritation, by blisters, setons, or issues, 
may be expedient : beyond these general directions, the practitioner will 
proceed according to the exigencies of the case, never omitting the 
weaning of the child. The convalescence of such patients is generally 
protracted and difficult, years sometimes elapsing prior to recovery. 
Nor can it be too strongly recommended, that suckling should be aban- 
doned, if a fresh pregnancy succeed very quickly. The symptoms are 
often rendered worse by gestation, and Invariably by a renewed lacta- 
tion. ^ Iron, chalybeate waters, country and sea air, travelling, and 
exercise, are most important auxiliaries. Every case will demand a 
curative or preventive treatment; and it will be fortunate for the 
patient if the approach of organic symptoms be described sufficiently 
early to obviate their full establishment. 



516 APPENDIX. 



CASES. 

It were easy to increase the length of this Appendix, by appending 
to it cases of a common functional kind : but these are so often seen, 
that they must be familiar to every practitioner. 



Case 1. 
INSANITY RESULTING FROM UNDUE SUCKLING. 

REPORTED BY MR. LEVER. 

Mrs. P., aged 28, of fair complexion, blue eyes and light hair, at the age of seven- 
teen suffered from chlorosis ; but under a course of tonics, and the advantages of 
sea air, she recovered. In twelve months she again relapsed, and again recovered 
under the same treatment. At the age of nineteen she married; and before her 
twentieth year she had a living male child. She nursed this child for twelve 
months, and was again confined soon after she had reached her twenty-first year. 
Since this period she has borne four living children, and has miscarried twice: she 
has nursed every child. Her last infant was born eight months before I saw her. 
My attendance was requested, on account of her having become very weak, very 
desponding, and sharp in her manner. On visiting her, 1 was struck with her pale, 
anxious countenance ; the pupils were dilated; the pulse was small, quick, and irri- 
table. She complained of great thirst, of a pain at the top and back of her head, 
and there was also excessive leucorrhoea. I obtained answers to my questions} with 
some difficulty ; although in general she was exceedingly communicaiive. Tonics, 
change of air, &c, were ordered, and the child was partially weaned and fed. The 
symptoms, however, became worse, and her conduct was exceedingly violent. She 
attempted more than once to destroy both her husband and child. The latter was 
immediately removed, her head was shaved, nutritious but unstimulating diet was 
ordered, together with tonics and sedatives. These measures were diligently pro- 
secuted ; but at length it was thought right to remove her to an asylum. Here she 
continued four months, and returned home entirely recovered. Ten months subse- 
quently she was again confined of a living child ; and within five months the insa- 
nity returned. After a fruitless employment of remedies, she was again placed 
under restraint; and having remained there five months, she was sent home quite 
well. Twelve months from this period she gave birth to another living infant ; and 
at the suggestion of her medical attendant, she did not attempt to nurse it, and her 
intellect has continued unimpaired. 

Remarks. — This is an admirable illustration of the opinions advanced : clearly de- 
monstrating the dependence of the insanity on the suckling. It also proves that 
weaning is the only efficient preventive remedy. 



Case 2. 

INSANITY RESULTING FROM UNDUE SUCKLING. 

Mrs. J., aged 35 (July, 1837), is the mother of five children, and has been mar- 
ried seven years. She is fair, and has light eyes and hair. Hitherto she has nursed 



APPENDIX. 517 

her children very long ; and during the last lactation, she was often flighty, passion- 
ate, and inconsistent. 

On my visit, I was struck with her excited and irritable manner. Her face was 
flushed ; her eyes were directed very quickly to a variety of objects ; and she at- 
tempted more than once to get out of the room. On inquiry, I found she had nursed 
already fifteen months, and was determined still to persevere; nor had she allowed 
the child to be fed even once in the day. The pulse was quick and feeble; the 
tongue coated with a brownish fur; the appetite destroyed ; and the pain at the pit 
of the stomach was very severe. I ordered a mild aperient, great quietude, with 
some saline effervescent medicine; and I insisted that the child should be weaned; 
as this measure had, in her previous aberration, entirely cured her. 

I saw her ten days afterwards, and, excepting that she was somewhat reserved, 
she was clearly better. 

In three months she was entirely restored. 



Case 3. 

PHTHISIS RESULTING FROM UNDUE SUCKLING. 

Mrs. W., aged 25, living in Spitalfields, is the mother of five children, and has, 
contrary to my injunctions, nursed the last two for seventeen months each. In 
July, 1828, when I visited her, she was emaciated ; had a short, hacking cough ; 
complained of pain at the epigastrium and in the chest, particularly an the right 
side of the thorax; the pulse was 120, quick, and easily compressed; there were 
morning perspirations, and the sputa were purulent. Fifteen months had elapsed 
since her confinement; and during the last six, there has been constant alvine and 
stomachic derangement. The diet and porter had been increased largely during 
the last six months, in the vain hope that a larger supply of milk would be furnished, 
frequent purgatives have been employed; and the indigestion and flatulence, as 
well as the evening fever, have been correspondingly aggravated. The stethoscope 
detects a large vomica in the apex of the right lung. Immediate weaning was en- 
joined ; and every measure adopted calculated to arrest the progress of the organic 
lesion. She died, howsver, in a few weeks. 



Case 4. 

SOFTENING AND ABSCESS OF THE BRAIN FROM UNDUE 

SUCKLING. 

Mrs C. aged SO, had been confined in April, 1830, of her first child. She was 
attended by Mr. E. Smith of Biliter Square; and although the labour was natural, 
it was protracted, and she was a good deal exhausted ; there was some hemorrhage 
subsequent to the expulsion of the placenta ; and the ergot was given for thirty-six 
hours afterwards, in doses of fifteen drops of the tincture every four or six hours. 
Her recovery was slow, but satisfactory ; she nursed the child well ; and three 
months prior to her death, having then suckled her infant nearly twelve months, she 
complained of great weakness, but especially of headache. She was advised very 
strongly to wean the child, but peremptorily refused to do so. An improved diet, 
and vegetable tonics, were prescribed ; and care was observed in preserving a healthy 
condition of the alvine evacuations. It ought to be observed, that she had menstru- 
ated tor the two preceding months. At intervals of a week or ten days, I saw Mrs. 
U, and never failed most pertinaciously to urge the weaning, without success, till 
about a month before her death. The headache had become so severe as to pro- 
duce temporary loss of consciousness; aid the pain occurring periodically in pa- 
roxysms, it assumed the character of an epileptic seizure. In a day or two after- 
34 



518 APPENDIX. 

wards, the intense suffering was confined especially to the right side of the head ; 
and as it was often preceded by shivering, and attended with violent jactitation, it 
was presumed it might be an intermittent. The seizures, however, became more 
decidedly epileptic and convulsive; and, resisting every plan of treatment, in fifteen 
months from the commencement of lactation, she died. For three or four days be- 
fore her decease, she was totally insensible, breathing stertorously, and devoid of all 
power of the bladder or rectum. 

Sectio Cadaveris. — On removing the calvaria, the dura mater was found studded 
with little bloody spots, and its vessels were gorged with blood. In the middle 
lobe there was a cavity, about the size of a walnut, filled with pus; immediately 
anterior to this, there were three distinct tubercular bodies, of the size of large 
nuts : one hard, and the other softened down. In the same hemisphere (the right) 
there was general softening ; the other parts of the brain were tolerably healthy. 
The uterus was flaccid and large, and its lining membrane very soft; and towards 
the lower part of the cavity it was slightly abraded. The body generally was ema- 
ciated. Prior to the nursing, Mrs. C. was unusually lively and intelligent. 



Case 5. 

reported by mr. john mills, clinical clerk. . 

Mary J , set. 42, admitted under Dr. Ashwell, Dec. 2d, 1842 ; an unhealthy, 

emaciated-looking female ; was early married, and has given birth to nine children, 
besides miscarriages. She has never suckled any child less than two years (the 
last was not weaned'until the expiration of two years and eight months), and has all 
this time been exposed to the miseries of poverty, frequently wanting even the ne- 
cessaries of life. No wonder, then, that the most extensive constitutional debility 
should be induced, and that a disorder of comparatively trivial moment in a healthy 
individual, should here have excited serious and alarming indications. 

Three weeks ago Mrs. J. was cpnfined ; her labour was good, and she felt as well 
as usual for some days afterwards, though from causes above stated she was in a very 
unfit state to undergo the excitement and shock of parturition. She had observed 
a weakness in the left leg and foot for some weeks, which rendered her rather lame, 
and in both limbs the veins have always been remarkably varicose. One week 
after delivery, she was suddenly seized with violent pain in the left foot; swelling 
immediately commenced, and "in fifteen minutes the leg and foot were the size of 
a child? 8 body." This is the statement she gives and persists in, although the gen- 
tleman who attended her denies that swelling of the limb took place at any precise 
period. To relieve the pain and counteract heat, leeches and poultices were ap- 
plied; an extensive and unhealthy ulcer followed in a few days; and now, on her 
admission, the whole of the outer side of the left foot and ankle is one mass of slough- 
ing ulceration, and very painful. _ ■ 

The constitution is supported, though with difficulty, by wine and other stimu- 
lants ; there is considerable hectic fever; she is irritable, and dozes a great part of 
the day. Pulse weak and trembling, bowels open, tongue white and flabby. Or- 
dered, Ammon. Sesquicarb. 9ij.; Tinct. Lupuli,^ss. ; Infus. Serpent, ^iiis. \ Cochl. 
iij. tu die ; Catapl. Cerevisiae. 

Dec. Ath. — Slept tolerably last night; feels easier this morning; wound more 
healthy. Wine, ^vj. ; Porter, one pint. 

5th. — Poultice appears to agree well with the ulcer, and she does not feel much 
pain .except when it is examined; feels better in health. 

6th. — Is certainly improved ; appetite tolerable. 

^ik. — Slept well last night ; profuse perspiration. 

8//j,. — Wound painful; otherwise improving. Lot. Acid. Nit. 

9^ — No particular alteration : not any considerable suffering from the wound. 

13^. — Improving : complains much of the nitric acid lotion, which is, however, of 
meat benefit. Qufnaa Disulph. gr. iij. t. d. : P. Lotis. Acid. Nit. pro Catapl. 



APPENDIX. 519 

21s?.— Health very much improved ; wound in a favourable state. 

Feb. 5th.— Wound looking healthy and healing; she cannot bear it stopped up, so 
has it dressed simply with dry lint. 

From the 21st of December until March, the prognosis was on the whole favour- 
able, although slow. On the 5th of March, 1843, the wound was dressed with black 
wash poultices by night, and black wash or lint by day, argenti nitras having been 
previously used. She had entirely recovered her health, but could not walk without 
support. 

March 6th. — Sore healing slowly ; very much depressed in the centre ; granu- 
lations small. To use simple water-dressing and oiled silk. 

15^.— Wound looking a little better; not quite so deep. Argent. Nit. applied in 
a crucial stripe. 

nth — Sore better; considerably lessened in size. 
22d. — Decidedly improved ; rilling up rapidly. 

I have inserted this case, because it shows that extensive organic 
mischief may arise from undue suckling ; a fact not well known, at 
least till lately. 



The following interesting and successful exemplification of the pro- 
priety of inducing labour prematurely and artificially, where disease exists 
in the mother, was transmitted too late to allow of its insertion in the 
chapter devoted to this most important subject. 



PREGNANCY COMPLICATED WITH ABDOMINAL TUMOURS. 

REPORTED BY THE HUSBAND OF THE PATIENT, HIMSELF A SURGEON PRACTISING 

MIDWIFERY. — MARCH, 1842. 

Mrs. , aetat. 36, of a weak and delicate constitution, about five years aao first 

perceived an enlargement of the right ovary, accompanied by the usual symptoms of 
local pain, and weight and irritability of the bladder. It has since been slowly in- 
creasing, and is now about the size of the fcetal head, and apparently nearly solid in 
structure. About two years afterwards, the functions of the uterus, which had pre- 
viously continued regular, becoming much impaired and attended with considerable 
pain, another tumour, of the size of a walnut, was discovered in the posterior wall 
of the uterus, contiguous to the recto-vaginal septum, and this has since generally 
remained in a quiescent state, and given little uneasiness. Eighteen months aero, 
the symptoms of pregnancy made their appearance, and between the fifth and sixth 
months of gestation, when the pain from the pressure on the tumours was becoming 
severe, spontaneous abortion took place. ° 

At the beginning of last autumn, Mrs. -again became preo-nant, and arrived 

at the seventh month, and for the last three or four weeks of that time had been suf- 
fering constant and considerable pain in the tumours, with more or less tenderness 
on pressure; and the danger of inflammation shortly supervening appeared imminent, 
the abdomen being tense, with great aggravation of pain when walking A aentle 
carriage drive of a mile or two also much increased the severity of the symptoms. 
It was agreed, under these circumstances, to solicit the advice of Dr. Ashwell, who, 



520 APPENDIX. 

after a careful investigation, decided on the necessity of the induction of premature 
labour. 

On the 8th instant, he accordingly punctured the membranes with a stilletted ca- 
theter, which operation was shortly followed by a profuse discharge of liquor amnii. 
In the course of the first twelve hours, it was estimated that not less than six or 
seven pints of this fluid were evacuated. This inordinate secretion had no doubt 
been occasioned by the constant pressure and irritation produced by the tumours on 
the uterus. On the 10th, labour pains set in, and were soon followed by the birth of 
a still-born child. For several days succeeding delivery, there was considerable 
tenderness and irritation of the tumours, which yielded to the recumbent posture, 
anodynes, and aperients. She is now, three weeks from the accouchement, perfectly 
well. 



THE END. 



311-77-2 



